What is the best management approach for a patient with impaired renal function (GFR of 60), slightly elevated urine microalbumin, and no diabetes or hypertension?

Management of CKD Stage 3a with Microalbuminuria in Non-Diabetic, Non-Hypertensive Patient

Start an ACE inhibitor or ARB immediately and titrate to maximum tolerated dose, as this patient has CKD with albuminuria ≥30 mg/24 hours, which mandates renin-angiotensin system blockade regardless of blood pressure status. 1

Blood Pressure Management

Even without a diagnosis of hypertension, this patient requires careful blood pressure assessment and likely treatment:

• Target blood pressure <130/80 mmHg because albuminuria is present (≥30 mg/24 hours equivalent), per KDIGO 2012 guidelines 1
• If blood pressure is consistently >130/80 mmHg, initiate BP-lowering drugs with ACE inhibitor or ARB as first-line 1
• If blood pressure is <130/80 mmHg, ACE inhibitor or ARB is still indicated specifically for proteinuria reduction and renal protection 1

ACE Inhibitor or ARB Initiation

Both ACE inhibitors and ARBs are equally effective for renal protection—choose based on tolerability, not efficacy differences 2:

• Start at standard dose and titrate to maximum tolerated dose, as clinical trials demonstrating renal protection used maximal dosing 2
• Monitor serum creatinine/eGFR and potassium within 2-4 weeks of initiation, then at least annually 2
• Accept up to 30% increase in creatinine after starting therapy—this is expected and does not require discontinuation 1
• Discontinue only if creatinine continues to rise beyond 30% or refractory hyperkalemia develops 1

Critical Pitfalls to Avoid

• Never combine ACE inhibitors with ARBs—multiple trials show increased adverse events without additional cardiovascular or renal benefits 2
• Do not underdose—the renoprotective effects demonstrated in trials required maximum tolerated doses 2
• Avoid NSAIDs and monitor for nephrotoxin exposure, as CKD patients are at increased risk for acute kidney injury 1, 3
• Monitor for hyperkalemia, especially if adding potassium-sparing diuretics or mineralocorticoid receptor antagonists 2

Additional Management Strategies

Lifestyle interventions are essential for slowing CKD progression 1:

• Restrict dietary sodium to <2 g per day 1
• Target BMI 20-25 kg/m² 1
• Smoking cessation if applicable 1
• Exercise 30 minutes, 5 times per week 1

Monitoring Schedule

• Repeat creatinine, eGFR, and electrolytes in 2-4 weeks after starting ACE inhibitor/ARB, then every 3-6 months 2, 3
• Annual urine albumin-to-creatinine ratio to assess treatment response and disease progression 3
• Monitor for CKD progression defined as both a change in GFR category AND ≥25% decline in eGFR 1

Nephrology Referral

This patient does not yet require nephrology referral, as the threshold is eGFR <30 mL/min/1.73 m² 3. However, refer if:

• eGFR declines to <30 mL/min/1.73 m² 3
• Rapid progression occurs (≥25% eGFR decline with category change) 1
• Difficulty managing hypertension or hyperkalemia develops 1

Investigate Underlying Cause

Since this patient lacks diabetes or hypertension (the two most common causes of CKD), investigate for alternative etiologies:

• The presence of albuminuria without retinopathy or within 10 years of any potential diabetes onset suggests possible non-diabetic kidney disease 1
• Consider urinalysis with microscopy to evaluate for glomerular disease 4
• Assess for other risk factors including dyslipidemia, family history of kidney disease, and cardiovascular disease 1, 4