Does an elevated Urine Albumin-to-Creatinine Ratio (UACR) indicating Impaired renal function in an elderly patient constitute Chronic Kidney Disease (CKD), necessitating immediate initiation of an Angiotensin-Converting Enzyme inhibitor (ACE) or an Angiotensin Receptor Blocker (ARB), or should the test be repeated?

From the Guidelines

A UACR of 500 mg/g indicates significant albuminuria and is consistent with chronic kidney disease (CKD), and this elderly patient should be started on an ACE inhibitor or ARB promptly, without waiting three months to repeat the test. The most recent and highest quality study, 1, recommends initial treatment with an ACE inhibitor or ARB for patients with albuminuria (UACR ≥30 mg/g) to reduce the risk of progressive kidney disease. Recommended medications include lisinopril (starting at 5-10 mg daily) or losartan (25-50 mg daily), with dose adjustments based on blood pressure response and kidney function.

• Before starting treatment, baseline serum creatinine and potassium should be checked, with follow-up labs within 1-2 weeks of initiation.
• These medications are beneficial because they reduce intraglomerular pressure, decrease proteinuria, and slow CKD progression.
• They also provide cardiovascular protection, which is particularly important in elderly patients with kidney disease.
• The patient should be monitored for potential side effects including hyperkalemia, acute kidney injury, and angioedema.
• If the patient cannot tolerate an ACE inhibitor due to cough, switching to an ARB is appropriate.
• Concurrent management should include blood pressure control, diabetes management if applicable, and avoidance of nephrotoxic medications, as suggested by 1.

From the FDA Drug Label

1. 4 Dual Blockade of the Renin-Angiotensin System (RAS) Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, syncope, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy The Veterans Affairs Nephropathy in Diabetes (VA NEPHRON-D) trial enrolled 1448 patients with type 2 diabetes, elevated urinary-albumin-to-creatinine ratio, and decreased estimated glomerular filtration rate (GFR 30 to 89.9 mL/min), randomized them to lisinopril or placebo on a background of losartan therapy and followed them for a median of 2. 2 years.

The FDA drug label does not answer the question.

From the Research

Chronic Kidney Disease Diagnosis

• A UACR of 500 is considered high and indicates chronic kidney disease (CKD) 2, 3.
• The diagnosis of CKD is associated with many important aspects of care, including patient awareness, patient engagement, and improved implementation of evidence-based interventions 4.

Treatment Options

• Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are commonly used to reduce the risk of cardiovascular events and delay end-stage kidney disease in patients with CKD 5.
• ACEIs have been shown to be superior to ARBs in lowering the risk of all-cause death in patients with advanced diabetic kidney disease 5.
• However, ACEIs and ARBs may have different effects on kidney events and cardiovascular outcomes, and the choice of treatment should be individualized based on the patient's specific condition and risk factors 5.

Testing and Monitoring

• Routine primary care case finding for CKD with estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (uACR) should focus on risk conditions, particularly diabetes, hypertension, and cardiovascular disease 4.
• The UACR test should be repeated to confirm the diagnosis of CKD, as a single elevated reading may not be sufficient to diagnose the condition 2.
• Regular monitoring of UACR and eGFR is necessary to assess the progression of CKD and adjust treatment accordingly 4.

Management and Prevention

• Individualized care that tailors CKD interventions proportional to the adverse outcome risk or the eGFR and uACR heat map is a major challenge for primary CKD care 4.
• A coordinated care approach to CKD management is necessary to deploy best practice in chronic disease management that engages the interdisciplinary team 4.
• Early detection of albuminuria and careful evaluation of UACR, even within normal range, can help reduce mortality risk 3.