Management of Proteinuria and eGFR 60
Diagnostic Steps
- The American Journal of Kidney Diseases recommends obtaining spot urine albumin-to-creatinine ratio (ACR) or protein-to-creatinine ratio (PCR) to determine the severity and type of proteinuria 2, 3
- If ACR ≥60 mg/mmol or PCR ≥100 mg/mmol, this indicates significant proteinuria requiring nephrology referral 1
- Proteinuria of grade 1+ on dipstick warrants quantification 4, 3
Treatment Algorithm
- The Kidney International guidelines suggest initiating ACE inhibitor or ARB therapy if hypertensive or if proteinuria persists despite treating underlying cause 5, 7
- Target systolic blood pressure <120 mmHg using standardized office measurement 7
- Uptitrate ACE inhibitor or ARB to maximally tolerated dose 5, 7
- Monitor serum creatinine and potassium within 1-2 weeks of initiation; accept up to 30% increase in creatinine if stable 7
Nephrology Referral Criteria
- The American Journal of Kidney Diseases recommends mandatory referral for persistent proteinuria >1 g/day (ACR ≥60 mg/mmol or PCR ≥100 mg/mmol) as biopsy and immunosuppression may be indicated 1
- eGFR <30 mL/min/1.73 m² (though this patient has eGFR 60) 1, 8
Blood Pressure Management
- Target systolic BP <120 mmHg in most patients 7
- Use ACE inhibitor or ARB as first-line agent 5, 7
- Add loop diuretics for volume management if needed 5, 7
- Restrict dietary sodium to <2.0 g/day (<90 mmol/day) 5, 7
Hyperkalemia Management
- Use potassium-wasting diuretics and/or potassium-binding agents to maintain normal potassium, allowing continuation of ACE inhibitor/ARB 7
- Treat metabolic acidosis if serum bicarbonate <22 mmol/L 7