What are the next steps for an elderly patient with hypertension and impaired renal function, who had an initial elevated albumin-to-creatinine ratio (ACR) of 103, now decreased to 43 after several months?

Next Steps for Elderly Patient with Improved Albuminuria

Continue current antihypertensive therapy and recheck the albumin-to-creatinine ratio in 3-6 months to confirm sustained improvement, while ensuring blood pressure remains at target (<140/90 mmHg for elderly patients). 1

Understanding the Clinical Significance

The initial ACR of 103 mg/g indicated moderately increased albuminuria (previously called "microalbuminuria," defined as 30-300 mg/g), which has now improved to 43 mg/g—still in the moderately increased range but showing a 58% reduction. 1 This improvement suggests that:

• Current blood pressure management is effective at reducing glomerular hyperfiltration 2
• The patient is responding well to therapy, which reduces cardiovascular risk 2
• The albuminuria has not resolved completely (normal is <30 mg/g), so continued monitoring and treatment optimization remain necessary 1

Confirm the Improvement is Sustained

Repeat the ACR measurement in 3-6 months to verify this is a true sustained improvement rather than biological variability. 1 Albuminuria can fluctuate due to:

• Hydration status at time of collection 1
• Recent physical activity or illness 1
• Dietary sodium intake variations 2

A single improved value requires confirmation before making major treatment changes. 1

Optimize Blood Pressure Control

Ensure blood pressure is consistently at target (<140/90 mmHg for elderly patients without diabetes). 1 The 2024 ESC guidelines recommend:

• For elderly patients who tolerate therapy well, consider targeting 120-129 mmHg systolic if achievable without adverse effects 1
• However, apply the "as low as reasonably achievable" (ALARA) principle if treatment is poorly tolerated 1
• Avoid excessive diastolic lowering below 60 mmHg, which may increase cardiovascular mortality in elderly patients 1

Verify RAAS Blocker Therapy

Confirm the patient is on an ACE inhibitor or ARB, as these are the preferred agents for hypertension with albuminuria. 1, 2, 3 Even with improved albuminuria:

• RAAS blockers provide blood pressure-independent antiproteinuric effects 2
• They should remain the cornerstone of therapy unless contraindicated 2, 3
• Do not discontinue or reduce RAAS blocker dose based solely on improved albuminuria 3

If not currently on a RAAS blocker, initiate one now despite the improvement, as residual albuminuria (43 mg/g) still warrants this therapy. 2, 3

Monitor Renal Function

Check serum creatinine, eGFR, and potassium within 2-4 weeks if any medication changes are made. 2, 3 For stable patients:

• Monitor renal function every 6-12 months 1, 3
• A creatinine increase up to 30% after RAAS blocker initiation or dose increase is acceptable and not a reason to discontinue 1, 2
• More than 30% increase warrants investigation for volume depletion, renovascular disease, or nephrotoxic agents 1

Assess for Orthostatic Hypotension

Measure blood pressure in both sitting and standing positions (after 5 minutes sitting, then 1 and 3 minutes after standing) to detect orthostatic hypotension, which is more common in elderly patients. 1, 2 This is particularly important before intensifying therapy. 1

Reinforce Non-Pharmacological Measures

Emphasize dietary sodium restriction to <2.0 g/day to enhance the antiproteinuric effect of medications. 2 Additional measures include:

• Weight normalization if overweight 2
• Regular physical activity distributed over at least 3 days per week 1
• Alcohol moderation 1

Common Pitfalls to Avoid

• Do not discontinue RAAS blocker therapy based on improved albuminuria—the patient still has residual albuminuria (43 mg/g) and requires continued renoprotection 2, 3
• Do not combine two RAAS blockers (ACE inhibitor plus ARB), as this provides no additional benefit and increases harm 1, 3
• Do not withhold treatment due to age alone—elderly patients benefit from antihypertensive therapy if well tolerated 1
• Do not ignore diastolic blood pressure—excessive lowering below 60 mmHg may be harmful in elderly patients 1, 4

Long-Term Monitoring Strategy

Once albuminuria and blood pressure are stable:

• Recheck ACR every 6-12 months to monitor for progression or further improvement 3
• Annual assessment of cardiovascular risk factors including lipids and glucose 1
• Monitor for development of other hypertension-mediated organ damage 1
• Adjust therapy if ACR increases above 300 mg/g (severely increased albuminuria) or if blood pressure becomes uncontrolled 1, 2