What is the recommended management for an adult patient with impaired renal function, proteinuria, and hypertension, possibly with pre-existing conditions such as diabetes or hypertension?

Management of Hypertension and Proteinuria with Impaired Renal Function

Start an ACE inhibitor or ARB immediately and titrate to maximum tolerated dose, target blood pressure ≤130/80 mmHg, and initiate an SGLT2 inhibitor for comprehensive kidney protection. 1, 2, 3

Immediate Assessment and Risk Stratification

Your patient presents with:

• ACR 50 mg/g (moderate albuminuria, A2 category) 1
• Creatinine 1.7 mg/dL (estimated eGFR likely 30-60 mL/min/1.73 m², CKD stage G3) 1
• Blood pressure 150/70 mmHg (systolic hypertension requiring treatment) 1

This patient requires twice-yearly monitoring of both eGFR and UACR given the ACR >30 mg/g and likely eGFR 30-60 mL/min/1.73 m². 1

Step 1: Initiate RAS Blockade as First-Line Therapy

Start either an ACE inhibitor (lisinopril 10 mg daily) or ARB (losartan 50 mg daily) immediately. 1, 3, 4 KDIGO guidelines specifically recommend ACE inhibitor or ARB for both diabetic and non-diabetic adults with CKD and urine albumin excretion ≥30 mg/24h (equivalent to ACR ≥30 mg/g). 1

• Titrate to maximum tolerated dose (lisinopril up to 40 mg daily or losartan up to 100 mg daily) for optimal renoprotection beyond blood pressure control alone. 2, 5, 6
• Accept up to 30% increase in serum creatinine after initiation—this hemodynamic effect is expected and does not indicate harm. 7
• Recheck creatinine and potassium in 1-2 weeks after starting or dose escalation. 2

The evidence strongly supports RAS blockade as superior to other antihypertensive classes for reducing proteinuria and slowing CKD progression, independent of blood pressure reduction. 5, 6, 8

Step 2: Target Blood Pressure ≤130/80 mmHg

Your target is systolic BP ≤130 mmHg and diastolic BP ≤80 mmHg given the presence of albuminuria ≥30 mg/g. 1, 9 KDIGO 2014 guidelines recommend BP ≤130/80 mmHg for patients with albuminuria ≥30 mg/24h (equivalent to ACR ≥30 mg/g). 1

• If BP remains >130/80 mmHg on maximum tolerated ACE inhibitor/ARB, add a thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) or long-acting dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily). 4, 6
• Most patients with CKD and proteinuria require 2-3 antihypertensive agents to achieve target BP. 5, 10

The 2022 Mayo Clinic guidelines note that for patients with 10-year ASCVD risk >15%, BP target should be <130/80 mmHg, which applies to most patients with CKD and proteinuria. 1

Step 3: Add SGLT2 Inhibitor for Kidney Protection

Initiate an SGLT2 inhibitor (dapagliflozin 10 mg daily or canagliflozin 100 mg daily) if eGFR ≥20 mL/min/1.73 m². 2 The American College of Cardiology recommends SGLT2 inhibitors as foundational first-line therapy for all CKD patients, regardless of diabetes status. 2

• SGLT2 inhibitors provide additive renoprotection to ACE inhibitors/ARBs and reduce cardiovascular mortality. 2, 7
• Continue SGLT2 inhibitor even as eGFR declines below 20 mL/min/1.73 m² until dialysis or transplantation. 2

Step 4: Implement Mandatory Lifestyle Modifications

Restrict dietary sodium to <2 g/day—sodium restriction enhances the antiproteinuric effect of ACE inhibitors/ARBs by 30-50%. 2, 7

Additional modifications include:

• Target BMI 20-25 kg/m² through weight management if overweight. 9, 2
• Smoking cessation immediately if applicable. 7
• Regular aerobic exercise 150 minutes per week. 9
• Consider plant-based diet to reduce red meat intake. 7

Step 5: Evaluate for Underlying Causes

Determine if diabetes is present by checking HbA1c and fasting glucose, as this patient has classic diabetic kidney disease features (proteinuria, hypertension, impaired renal function). 1, 11

• If diabetic with HbA1c >7%, optimize glycemic control to target HbA1c <7% to reduce microvascular complications. 1, 7
• Screen for diabetic retinopathy if diabetes confirmed, as its presence correlates with worse renal prognosis. 1, 11
• Evaluate for other causes of CKD: family history of polycystic kidney disease, autoimmune disorders, chronic infections (HIV, hepatitis C), or nephrotoxic exposures. 1

Step 6: Initiate Statin Therapy for Cardiovascular Protection

Start moderate-to-high intensity statin therapy (atorvastatin 40 mg daily or rosuvastatin 20 mg daily) for all CKD patients ≥50 years. 2, 7

• Target LDL-C <70 mg/dL in very high-risk patients with proteinuria. 7
• Monitor lipids 4-12 weeks after initiation, then annually if at goal. 7

Step 7: Monitoring Schedule

Reassess every 3-6 months with the following parameters: 2

• Serum creatinine and eGFR
• Urine albumin-to-creatinine ratio
• Electrolytes (sodium, potassium)
• Blood pressure
• Hemoglobin (screen for anemia of CKD)
• Lipid panel

More frequent monitoring (every 2-4 months) is warranted given ACR >30 mg/g and likely eGFR 30-60 mL/min/1.73 m². 1, 9

Step 8: Nephrology Referral Criteria

Refer to nephrology if eGFR <30 mL/min/1.73 m², persistent electrolyte abnormalities, or uncontrolled hypertension despite multiple agents. 2

• Early nephrology involvement is critical for patients with rapidly declining eGFR (>5 mL/min/1.73 m²/year) or proteinuria >1 g/day. 1

Critical Medications to AVOID

Avoid NSAIDs completely—they increase risk of acute kidney injury and accelerate CKD progression. 2

Avoid metformin if eGFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk. 2

Common Pitfalls to Avoid

Do not withhold ACE inhibitor/ARB due to mild creatinine elevation (<30% increase)—this is an expected hemodynamic effect and indicates appropriate glomerular pressure reduction. 7

Do not use dual RAS blockade (ACE inhibitor + ARB combination)—KDIGO guidelines state insufficient evidence to recommend this approach due to increased risk of hyperkalemia and acute kidney injury without additional benefit. 1

Do not delay SGLT2 inhibitor initiation while waiting for diabetes diagnosis—these agents benefit all CKD patients regardless of diabetes status. 2