What are the management recommendations for an adult patient with albuminuria and impaired renal function, potentially with hypertension or diabetes?

Management of Albuminuria 286 mg/g

Start an ACE inhibitor or ARB immediately, titrated to maximum tolerated dose, combined with an SGLT2 inhibitor (dapagliflozin 10 mg or canagliflozin 100 mg daily), regardless of blood pressure or diabetes status. 1, 2

Immediate Pharmacologic Interventions

RAS Inhibition (First-Line Mandatory Therapy)

• Initiate either an ACE inhibitor (lisinopril 10-40 mg daily) or ARB (losartan 50-100 mg daily, irbesartan 150-300 mg daily) immediately 1, 2, 3, 4
• This albumin level of 286 mg/g falls in the "moderately increased albuminuria" category (30-299 mg/g), which requires RAS blockade to prevent progression to severely increased albuminuria and reduce cardiovascular events 1, 2
• Titrate to maximum tolerated dose, not just blood pressure control—the kidney and cardiovascular protection is dose-dependent 2
• Monitor serum creatinine and potassium within 2-4 weeks after initiation or dose changes 2, 5
• Continue therapy if creatinine increases <30% from baseline 2, 5
• Never combine ACE inhibitor with ARB—this increases harm without additional benefit 2, 5

SGLT2 Inhibitor (Immediate Add-On Therapy)

• Start dapagliflozin 10 mg daily or canagliflozin 100 mg daily immediately if eGFR ≥20 mL/min/1.73 m² 2
• SGLT2 inhibitors provide kidney protection, reduce cardiovascular events, and decrease albuminuria independent of glucose-lowering effects, even in non-diabetic patients 2, 6
• Continue even as eGFR declines below 20 mL/min/1.73 m² until dialysis or transplantation 2

Blood Pressure Management

Target Blood Pressure

• Maintain blood pressure <130/80 mmHg 1, 2, 7
• For patients with albuminuria 30-299 mg/g, this lower target (compared to <140/90 mmHg for those without albuminuria) is essential to slow CKD progression 1
• Reduce blood pressure variability, as this independently predicts CKD progression 1
• Expect to require 3-4 antihypertensive medications to achieve target 7

Glycemic Control (If Diabetic)

• Target HbA1c of 7% to delay onset and progression of albuminuria 1, 2, 7
• Optimize glucose management to reduce risk or slow CKD progression 1
• Consider GLP-1 receptor agonists if type 2 diabetes, as they may help reduce albuminuria 6

Lifestyle Modifications

Dietary Interventions

• Restrict sodium to <2 g/day (<90 mmol/day or <5 g sodium chloride/day) 1, 2
• Limit protein intake to 0.8 g/kg/day 1, 2, 7
• Higher protein intake (>1.3 g/kg/day) increases albuminuria and accelerates kidney function loss 2
• Target BMI 20-25 kg/m² through weight management 2

Other Lifestyle Measures

• Smoking cessation is essential, as tobacco accelerates CKD progression 2

Additional Cardiovascular Risk Reduction

• Initiate moderate-to-high intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) for all patients ≥50 years with CKD, regardless of baseline lipid levels 2, 7
• Statins reduce cardiovascular events and mortality in CKD patients 2

Monitoring Schedule

• Monitor UACR and eGFR every 6-12 months for this level of albuminuria with presumed eGFR >60 mL/min/1.73 m² 1, 2
• If eGFR 30-59 mL/min/1.73 m² (stage G3 CKD), monitor every 6-12 months 2
• Monitor serum potassium in all patients on RAS inhibitors, especially with eGFR <60 mL/min/1.73 m² 2
• Recheck UACR after 3-6 months to confirm abnormal albumin excretion and assess treatment response 7

Nephrology Referral Criteria

• Refer immediately when eGFR <30 mL/min/1.73 m² 1, 2
• Refer for persistent electrolyte abnormalities despite management 2
• Refer for uncontrolled hypertension despite multiple agents 2
• Refer for rapid decline in eGFR (>5 mL/min/1.73 m² per year or >25% decline from baseline) 1, 2

Critical Medications to AVOID

• NSAIDs—increase acute kidney injury risk and blunt RAS inhibitor effectiveness 2, 6
• Avoid metformin when eGFR <30 mL/min/1.73 m² due to lactic acidosis risk 2
• Never use dual RAS blockade (ACE inhibitor + ARB)—increases harm without benefit 2, 5
• Avoid proton-pump inhibitors and iodinated contrast when possible 6

Common Pitfalls

• Do not wait for hypertension to develop before starting RAS inhibition—albuminuria alone is the indication 1, 2
• Do not use urine dipstick for screening—it misses microalbuminuria 2
• Do not discontinue RAS inhibitors for creatinine increases <30% 2, 5
• For hyperkalemia (K+ >5.5 mEq/L), implement potassium-lowering measures (dietary restriction, diuretics, sodium bicarbonate if acidotic) before discontinuing RAS inhibition 2

Advanced Therapy Consideration

• Add finerenone (nonsteroidal mineralocorticoid receptor antagonist) if persistent albuminuria despite maximum tolerated RAS inhibition and eGFR ≥25 mL/min/1.73 m² 2
• Finerenone provides additive kidney and cardiovascular protection beyond SGLT2 inhibitors and RAS blockade 2
• Monitor potassium closely when adding to RAS inhibition 2