Treatment of Moderately Increased Albuminuria

Primary Treatment Approach

The KDIGO 2021 guideline suggests starting RASI therapy (ACE inhibitor or ARB) for patients with CKD and moderately increased albuminuria (CKD G1 to G4; albuminuria category A2) without diabetes, despite the weaker evidence level (2C) 1.
The American Diabetes Association recommends ACE inhibitors or ARBs for patients with moderately increased albuminuria (30-299 mg/g), noting that therapy at maximum tolerated doses has reduced progression to more advanced albuminuria and slowed CKD progression 2.
The American College of Cardiology and other guideline societies support the use of ACE inhibitors, with options including Lisinopril: Start 10 mg daily, titrate to 20-40 mg daily, Enalapril: Start 5 mg daily, titrate to 10-40 mg daily in 1-2 divided doses, and Ramipril: Start 2.5 mg daily, titrate to 1.25-20 mg daily in 1-2 divided doses 3.
Alternatively, ARB options include Losartan: Start 25-50 mg daily, titrate to 25-100 mg daily, Irbesartan: Start 150 mg daily, titrate to 150-300 mg daily, and Valsartan: Start 80-160 mg daily, titrate to 80-320 mg daily 3, 4.

Monitor serum creatinine, eGFR, and potassium within 2-4 weeks of initiating therapy or any dose change, as recommended by the American Society of Nephrology 2, 5.
Continue therapy unless creatinine rises >30% within 4 weeks of initiation, as stated by the National Kidney Foundation 1.

Never combine ACE inhibitors with ARBs or direct renin inhibitors, as multiple large trials show no benefit on cardiovascular or CKD outcomes, but increased risks of acute kidney injury and hyperkalemia, according to the American Heart Association 1, 4, 2.
Avoid ACE inhibitors/ARBs in pregnancy due to fetal harm, as warned by the FDA and the American College of Obstetricians and Gynecologists 5.

Target sodium intake <2 g per day (<90 mmol/day, or <5 g sodium chloride per day), as recommended by the American Heart Association 1.
Recommend moderate-intensity physical activity for at least 150 minutes per week, as suggested by the Centers for Disease Control and Prevention 1.
Optimize glycemic control if diabetes is present, according to the American Diabetes Association 6, 7, 8.
Consider referral to nephrology when eGFR falls to 60 mL/min/1.73 m² or difficulties occur managing hyperkalemia, as recommended by the National Kidney Foundation 6, 7, 8.