Management of Microalbuminuria in Patients on Lisinopril

Definition and Significance of Microalbuminuria

Microalbuminuria is defined as urinary albumin excretion of 30-299 mg/g creatinine and represents an early stage of diabetic nephropathy, according to the American Diabetes Association 3, 4
Microalbuminuria is a well-established marker of increased cardiovascular risk and predicts progression to overt nephropathy, as stated by the American Diabetes Association 3, 4
Diagnosis requires at least two of three abnormal specimens collected within a 3-6 month period to account for variability in urinary albumin excretion, as recommended by the American Diabetes Association 3, 4

Continue surveillance of urinary albumin-to-creatinine ratio to assess both response to therapy and disease progression, as recommended by the American Diabetes Association 3, 4
The preferred method is measurement of albumin-to-creatinine ratio in a random spot collection, according to the American Diabetes Association 3, 4
Monitor serum creatinine and potassium levels regularly when using ACE inhibitors like lisinopril, as advised by the American Diabetes Association 5
Assess estimated glomerular filtration rate (eGFR) at least annually, as recommended by the American Diabetes Association 5

For patients with microalbuminuria already on lisinopril, consider titrating to the maximum approved dose of 40mg daily if tolerated, as recommended by the American Journal of Kidney Diseases 1, 2
In the absence of side effects or adverse events, titrate up to the maximum approved dose for hypertension, according to the American Journal of Kidney Diseases 2
The optimal dose for renoprotection may be higher than that required for blood pressure control alone, as stated by the American Journal of Kidney Diseases 1, 2

Maintain blood pressure below 130/80 mmHg in patients with diabetes and microalbuminuria, as recommended by the American Journal of Kidney Diseases 1
Higher levels of blood pressure are associated with more rapid progression of diabetic kidney disease, according to the American Journal of Kidney Diseases 1
Systolic blood pressure control may be more important than diastolic blood pressure control for kidney disease progression, as stated by the American Journal of Kidney Diseases 1

Optimize glycemic control as intensive diabetes management delays progression of microalbuminuria to macroalbuminuria, as recommended by the American Diabetes Association 3, 4
Consider adding an ARB if microalbuminuria persists despite maximum tolerated dose of lisinopril, though evidence for dual RAS blockade is limited, according to the American Journal of Kidney Diseases 2
Avoid combination of ACE inhibitors and ARBs as dual blockade as this increases risk of adverse events, particularly impaired kidney function and hyperkalemia, as advised by the American Journal of Kidney Diseases 2, 6

Monitor for hyperkalemia, especially in patients with reduced kidney function, as recommended by the American Diabetes Association 5 and the American Journal of Kidney Diseases 2
Watch for acute increases in serum creatinine, as advised by the European Heart Journal 7
Lisinopril is contraindicated in pregnancy due to risk of fetal harm, as stated by the American Journal of Kidney Diseases 2

Consider referral to a nephrologist when GFR falls below 60 mL/min/1.73m², as recommended by the American Diabetes Association 3, 4
Refer when there is uncertainty about the etiology of kidney disease or difficult management issues, as advised by the American Diabetes Association 5
Early referral has been found to reduce cost and improve quality of care, according to the American Diabetes Association 4