What is the recommended treatment for a patient with impaired renal function (eGFR of 60), elevated creatinine (1.19), and microalbuminuria (urine microalbumin ratio of 36)?

Management of Stage 3a CKD with Moderately Increased Albuminuria

For a patient with eGFR 60 mL/min/1.73 m² and urine albumin-to-creatinine ratio of 36 mg/g, initiate ACE inhibitor or ARB therapy immediately, optimize blood pressure control to target <140/90 mmHg (or <130/80 mmHg if tolerated), and ensure annual monitoring of both eGFR and albuminuria. 1

Classification and Risk Stratification

Your patient has:

• Stage G3a CKD (eGFR 60 mL/min/1.73 m²) 2
• Category A2 albuminuria (moderately increased: 30-299 mg/g) 1
• This combination indicates established chronic kidney disease requiring active intervention 2

The urine albumin-to-creatinine ratio of 36 mg/g places this patient in the A2 category, which confers approximately 50% increased cardiovascular risk independent of the eGFR 2. This level of albuminuria is strongly associated with both CKD progression and cardiovascular events 3.

Primary Treatment: RAAS Blockade

Start either an ACE inhibitor or ARB as first-line therapy. 1 Both drug classes have equivalent efficacy for:

• Reducing progression to macroalbuminuria (≥300 mg/g) 2
• Slowing CKD progression 2
• Reducing cardiovascular events 2

The choice between ACE inhibitor versus ARB depends on tolerability—if one class causes side effects (e.g., cough with ACE inhibitor), substitute the other 2. Target a ≥30% reduction in urinary albumin within 3-6 months of initiating therapy, as this predicts slower CKD progression. 4

Monitoring After RAAS Blockade Initiation

• Check serum creatinine and potassium within 1-2 weeks of starting therapy 1
• An acute rise in creatinine up to 30% is acceptable and does not require discontinuation 2
• Hold therapy if potassium rises above 5.5 mEq/L or creatinine increases >30% 2

Blood Pressure Management

Target blood pressure <140/90 mmHg at minimum; consider <130/80 mmHg given the presence of albuminuria. 2 Lower targets are particularly beneficial in patients with A2 or A3 albuminuria for slowing CKD progression 2.

If ACE inhibitor or ARB monotherapy does not achieve blood pressure goals:

• Add a thiazide-like diuretic or dihydropyridine calcium channel blocker 2
• These classes are equally effective for blood pressure control in CKD 2
• Avoid combining ACE inhibitor with ARB (increases adverse events without additional benefit) 2

Glucose Management (If Diabetic)

If this patient has diabetes:

• Metformin is safe and appropriate at eGFR 60 mL/min/1.73 m² 2
• Metformin can be continued until eGFR falls below 30 mL/min/1.73 m² 2
• Advise temporary discontinuation during acute illness, surgery, or contrast procedures ("sick day rules") 2

Consider adding an SGLT2 inhibitor or GLP-1 receptor agonist if additional glucose control is needed beyond metformin 2. These agents provide:

• Direct kidney protection independent of glucose lowering 2
• Reduction in CKD progression (SGLT2 inhibitors reduce progression by 39-44%) 2
• Cardiovascular risk reduction 2

Monitoring Schedule

Annual assessment is required at this CKD stage: 1

• Measure eGFR and urine albumin-to-creatinine ratio yearly 2, 1
• Confirm albuminuria with 2-3 specimens over 3-6 months before making treatment decisions 2, 1
• Avoid testing during acute illness, marked hyperglycemia, or within 24 hours of exercise (these transiently elevate albuminuria) 2

Increase monitoring frequency if: 2

• eGFR declines >5 mL/min/1.73 m² per year (suggests rapid progression)
• Albuminuria increases despite treatment
• New medications are added that affect kidney function

Nephrology Referral Criteria

Do not refer to nephrology at this stage unless specific complications arise 2, 1:

• Refer if eGFR falls below 30 mL/min/1.73 m² 2, 1
• Refer if rapid progression occurs (eGFR decline >5 mL/min/year) 1
• Refer if difficult-to-control hypertension or hyperkalemia develops 2
• Refer if uncertainty exists about CKD etiology 1

Common Pitfalls to Avoid

Do not use outdated terminology: The terms "microalbuminuria" and "macroalbuminuria" should be replaced with A1/A2/A3 categories 2, 1.

Do not rely on serum creatinine alone: eGFR is superior for assessing kidney function, and albuminuria provides independent prognostic information 5. Both must be measured 2.

Do not withhold RAAS blockade due to mild eGFR reduction: The benefits of ACE inhibitor/ARB therapy clearly outweigh risks at eGFR 60 mL/min/1.73 m² with albuminuria 2, 4.

Do not discontinue RAAS blockade for minor creatinine increases: Up to 30% acute rise is expected and acceptable 2. Only discontinue for hyperkalemia >5.5 mEq/L or creatinine increase >30% 2.

Counsel patients to temporarily hold RAAS blockers during acute illness (vomiting, diarrhea, dehydration) to prevent acute kidney injury 2.