Management of Moderately Increased Albuminuria

Assessment and Diagnosis

The American Diabetes Association classifies an albumin/creatinine ratio of 42 mg/g as "moderately increased" (30-299 mg/g) 1
At least two of three specimens collected within a 3-6 month period should be abnormal before confirming the diagnostic category, according to ADA recommendations 2

The American College of Cardiology recommends a blood pressure target of <130/80 mmHg for adults with hypertension and chronic kidney disease (CKD) 4, 5
The European Society of Cardiology recommends a systolic BP target range of 130-139 mmHg for older adults (≥65 years) with hypertension and CKD to balance benefits and risks 6
Clinical judgment, patient preference, and a team-based approach should be used to determine the intensity of BP lowering in elderly patients (≥65 years) 1

The American College of Cardiology recommends ACE inhibitors or ARBs as first-line therapy for patients with hypertension and albuminuria ≥30 mg/g 1, 4
ACE inhibitors or ARBs reduce albuminuria beyond their blood pressure-lowering effects and slow progression of kidney disease 2
The American College of Cardiology states that treatment with an ACE inhibitor is reasonable to slow kidney disease progression in adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d]) 5

If BP control is not achieved with an ACE inhibitor or ARB alone, adding a calcium channel blocker (CCB) or diuretic is recommended 7, 2
The American College of Cardiology recommends initial therapy with a thiazide-type diuretic or CCB, with the addition of an ACE inhibitor or ARB for albuminuria in black patients 4
For resistant hypertension, adding a mineralocorticoid receptor antagonist (MRA) like spironolactone should be considered 7, 2
The nonsteroidal MRA finerenone has lower rates of hyperkalemia compared to spironolactone and can reduce CKD progression 2

Check basic metabolic profile within 2-4 weeks of starting or adjusting ACE inhibitor or ARB therapy to monitor for changes in electrolytes or kidney function 1
Follow up every 6-8 weeks until BP goal is safely achieved, then every 3-6 months 1
Consider orthostatic hypotension testing by measuring BP after 5 minutes of rest in sitting or lying position, followed by measurements at 1 and/or 3 minutes after standing, especially in elderly patients 8

Avoid excessive BP lowering in elderly or frail patients due to increased risk of falls, acute kidney injury, and other adverse events 3
For patients aged ≥75 years with frailty, a slightly higher target may be appropriate if side effects occur 9
Avoid beta-blockers and alpha-blockers like terazosin in frail elderly patients unless specifically indicated 10, 8
Alpha-1 blockers are not recommended as first-line agents for hypertension and have been associated with higher incidence of heart failure in men with hypertension and cardiac risk factors 10