In an adult with an elevated urine albumin‑creatinine ratio, what medications, supplements, and lifestyle factors should be stopped?

Medications and Factors to Stop with Elevated Albumin-Creatinine Ratio

In adults with elevated urine albumin-creatinine ratio (≥30 mg/g), the primary focus should be on stopping nephrotoxic medications and modifying lifestyle factors that worsen kidney damage, rather than stopping protective therapies.

Medications to Stop or Avoid

NSAIDs and Nephrotoxic Agents

• Stop all non-steroidal anti-inflammatory drugs (NSAIDs) including ibuprofen, naproxen, and COX-2 inhibitors, as these directly impair renal perfusion and can accelerate kidney disease progression 1
• Discontinue or minimize use of other nephrotoxic medications when possible, including aminoglycosides, lithium, and calcineurin inhibitors (if applicable) 1

Contrast Media Precautions

• Avoid high-osmolar iodinated radiocontrast agents; if imaging is necessary, use the lowest possible dose with adequate hydration protocols 1
• Avoid gadolinium-containing contrast media if eGFR <30 mL/min/1.73 m²; if unavoidable, use macrocyclic chelate preparations 1

Medications Requiring Dose Adjustment (Not Necessarily Stopped)

• Do NOT routinely stop ACE inhibitors or ARBs - these are actually recommended for treatment when UACR ≥30 mg/g in diabetic patients and ≥300 mg/g in non-diabetic patients 1
• However, monitor serum creatinine and potassium levels closely when using ACE inhibitors, ARBs, or diuretics 1
• Reevaluate metformin use if eGFR <45 mL/min/1.73 m² (reduce to maximum 1,000 mg/day) and discontinue if eGFR <30 mL/min/1.73 m² 1

Lifestyle Factors to Stop

Dietary Modifications

• Stop excessive sodium intake - reduce to <90 mmol (<2 g) per day of sodium (corresponding to 5 g of sodium chloride) 1
• Stop high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 1
• For those with elevated triglycerides, decrease carbohydrate intake 1

Smoking Cessation

• Stop smoking immediately - smoking cessation is linked to reduction of proteinuria and slowing of CKD progression 1

Exercise Modifications

• Avoid vigorous exercise within 24 hours before urine collection for monitoring purposes, as this can falsely elevate UACR 2, 3
• However, regular moderate exercise (30 minutes 5 times per week) should be encouraged as part of lifestyle intervention 1

Supplements and Over-the-Counter Products to Stop

Herbal Supplements

• Stop potentially nephrotoxic herbal supplements including aristolochic acid-containing products, high-dose vitamin C (>1000 mg/day), and creatine supplements 1

High-Dose Protein Supplements

• Discontinue protein powders or supplements that result in total protein intake >1.3 g/kg/day 1

Critical Monitoring Points

When ACE Inhibitors/ARBs Should Be Reconsidered

• Important caveat: ACE inhibitors and ARBs should be avoided in individuals of childbearing age who are not using reliable contraception due to teratogenic effects 1
• Monitor serum creatinine and potassium when initiating or continuing these medications 1

Blood Pressure Management

• For patients with UACR ≥30 mg/g, target blood pressure should be <130/80 mmHg (more stringent than the <140/90 mmHg target for those with UACR <30 mg/g) 1
• For children and adolescents, target BP <90th percentile for age, sex, and height, or <130/80 mmHg if ≥13 years old 1

Referral Criteria

Refer to nephrology when 1:

• UACR ≥300 mg/g (persistent)
• eGFR <30 mL/min/1.73 m²
• Rapid progression (eGFR decline >5 mL/min/1.73 m² per year or >25% decline from baseline)
• Uncertainty about etiology of kidney disease
• Difficulty managing complications

Common Pitfalls to Avoid

• Do not stop ACE inhibitors or ARBs in patients with elevated UACR unless there are specific contraindications (pregnancy, hyperkalemia, acute kidney injury) - these medications are protective, not harmful 1
• Do not assume that stopping all medications is beneficial; the goal is selective discontinuation of nephrotoxic agents while maintaining renoprotective therapy 1
• Do not delay intervention until UACR reaches very high levels (≥300 mg/g); evidence shows that even mildly elevated UACR (10-30 mg/g) increases cardiovascular and renal risk 4, 5