What strategies exist for treating albuminuria in CKD patients?
Treating to an albumin target usually involves an escalation of RAAS blockade, which can be achieved by restricting dietary salt intake, increasing doses of an ACE-I or an ARB, combining the two classes of medication, or by adding a thiazide diuretic, an aldosterone- receptor blocker or a direct renin inhibitor (DRI). While a strong case has been made for targeting a reduction of albuminuria, particularly with agents that interfere with the RAAS, there have been no large studies in CKD patients reporting long term differences in GFR or CVD outcomes where reduction in urinary albumin levels (regardless of BP) was the primary objective. There is also uncertainty as to whether the dose of a particular agent that is required to achieve BP control is necessarily the same as the dose required for albuminuria reduction.24 The Work Group thus decided that it was premature to recommend an albuminuria reduction target strategy for all cases of CKD but felt this deserved further discussion in Chapter 8.