What is the best course of action for a patient with elevated blood pressure (hypertension), impaired renal function (eGFR 45), and a high albumin-to-creatinine ratio (ACR), who is currently taking 5mg of unspecified medication, likely for pain management?

Management of Elevated Blood Pressure and Declining Renal Function

Immediate Blood Pressure Management

Do not increase antihypertensive medication based solely on a single clinic reading of 163/79 mmHg—first confirm the diagnosis with home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM) to exclude white-coat hypertension, which is particularly common in patients with chronic kidney disease. 1, 2

Confirming the Diagnosis

• Arrange 7-day home blood pressure monitoring immediately, taking readings twice daily (morning and evening) with an average of 2 readings per session, 1-2 minutes apart 1
• Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms true hypertension requiring treatment intensification 1, 3
• White-coat hypertension is present in up to 58% of patients with elevated clinic readings and is particularly common in CKD patients 2, 4
• Out-of-office BP measurements better predict end-organ damage and mortality outcomes in CKD patients than clinic readings 2

If Hypertension is Confirmed (Home BP ≥135/85 mmHg)

For a patient with CKD (eGFR 45 mL/min/1.73 m²) and elevated albumin-to-creatinine ratio, target systolic BP to 120-129 mmHg if tolerated, as this patient has moderate-to-severe CKD with eGFR <60 mL/min/1.73 m². 1

• The 2024 ESC guidelines specifically recommend targeting systolic BP to 120-129 mmHg in adults with moderate-to-severe CKD who have eGFR >30 mL/min/1.73 m² and are receiving BP-lowering drugs, if tolerated 1
• Minimum acceptable target is <140/90 mmHg if the intensive target is not tolerated 1
• RAS blockers (ACE inhibitors or ARBs) are specifically recommended as part of the treatment strategy in hypertensive patients with elevated ACR, as they are more effective at reducing albuminuria than other antihypertensive agents 1

Medication Adjustment Strategy

If home monitoring confirms uncontrolled hypertension:

• Add an ACE inhibitor or ARB to the current regimen (assuming the "5 milligrams" refers to amlodipine or another calcium channel blocker), as RAS blockade is specifically indicated for patients with albuminuria 1, 3
• If already on a RAS blocker, add a thiazide-like diuretic (chlorthalidone 12.5-25mg or indapamide 1.25-2.5mg) as the third agent to achieve guideline-recommended triple therapy 1
• Fixed-dose single-pill combinations are strongly preferred over separate pills to improve adherence 1, 5
• Do not combine two RAS blockers (ACE inhibitor + ARB), as this increases adverse events without additional benefit 1

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Urgent Investigation of Declining Renal Function

The decline in eGFR from 56 to 45 mL/min/1.73 m² with elevated ACR represents moderate-to-severe CKD that requires immediate investigation—this has not been adequately evaluated and demands urgent workup for underlying causes. 1

Essential Immediate Investigations

It is recommended to measure serum creatinine, eGFR, and urine ACR at least annually in patients with moderate-to-severe CKD, but this patient requires more urgent evaluation given the unexplained decline. 1

Mandatory First-Line Tests:

• Repeat serum creatinine, eGFR (using race-free CKD-EPI equation), and urine ACR to confirm the decline and quantify albuminuria 1
• Renal ultrasound and Doppler examination should be considered to assess kidney structure, determine causes of CKD, and exclude renoparenchymal and renovascular hypertension 1
• 12-lead ECG to assess for left ventricular hypertrophy and other hypertension-mediated organ damage 1
• Full metabolic panel including serum potassium, calcium, phosphate, and bicarbonate 1
• Urinalysis with microscopy to assess for active sediment, hematuria, or casts 1
• Fasting lipid profile and HbA1c if not recently checked 1

Consider Secondary Causes:

Given the unexplained decline in renal function with hypertension:

• Screen for renovascular hypertension with CT or magnetic resonance renal angiography, particularly if the patient has other risk factors (age >55 years, atherosclerotic disease elsewhere, flash pulmonary edema, or asymmetric kidneys on ultrasound) 1
• Evaluate for primary aldosteronism if hypertension is difficult to control 1
• Consider obstructive sleep apnea screening, especially if the patient is overweight or has symptoms 1
• Review all medications for nephrotoxic agents (NSAIDs, proton pump inhibitors, etc.) 3

Monitoring Schedule for CKD

• Repeat measurements of serum creatinine, eGFR, and urine ACR at least annually once moderate-to-severe CKD is confirmed 1
• More frequent monitoring (every 3-6 months) is warranted given the recent decline and need to assess response to treatment intensification 1
• Monitor serum potassium and creatinine 1-4 weeks after initiating or intensifying RAS blocker therapy 1, 3

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Critical Pitfalls to Avoid

• Do not start or intensify antihypertensive medication without first confirming true hypertension with out-of-office BP monitoring, as clinic readings may significantly overestimate true BP in CKD patients 1, 2
• Do not delay investigation of declining renal function—the drop from eGFR 56 to 45 with elevated ACR requires urgent evaluation for reversible causes 1
• Do not target diastolic BP <80 mmHg, as excessive diastolic lowering may be harmful 1
• Do not withhold RAS blockers due to fear of worsening renal function—they are specifically indicated for patients with albuminuria and provide long-term renoprotection, though close monitoring is essential 1
• Individualized BP targets are recommended for those with eGFR <30 mL/min/1.73 m² or renal transplantation 1

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Lifestyle Modifications (Essential Concurrent Interventions)

• Restrict sodium to <2 g/day (approximately 5 g salt/day), which is particularly important in CKD and can provide additive BP reduction of 5-10 mmHg 1, 5
• Moderate-intensity aerobic exercise ≥150 min/week plus resistance training 2-3 times/week 1
• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Adopt Mediterranean or DASH diet 1, 5
• Limit alcohol to <100 g/week of pure alcohol (preferably avoid completely) 1, 5