To preserve kidney function, proteinuria should be targeted as actively as hypertension, to lower UACR (urinary albumin-creatinine ratio) as much as possible, ideally <50 mg/mmol with ACE inhibitors/ARBs (ARBs preferred as fewer cases of cough and the dose increased to maximum to attain the proteinuria goal).
Candesartan is preferred unless there is gout, whereas Losartan has the additional benefit of lowering uric acid. ACE inhibitors and ARBs have an anti-proteinuria effect over and above that achieved by lowering blood pressure alone. Other BP meds can do it but need at least a 20 mmHg drop to achieve the same protection. Titrate to maximum tolerated dose to achieve maximal anti-proteinuric effects.
When there is no microalbuminuria, low doses of different medications are considered optimal for lowering blood pressure with minimal adverse effects.
This Gem has been approved by Prof Rob Walker, Renal Physician, University of Otago.
