A 68-year-old woman with a 10-year history of hypertension is found to have an eGFR of 32 mL/min/1.73 m² on routine screening. Serum creatinine is 2.1 mg/dL. She is currently on amlodipine 5 mg daily. Urinalysis is normal (no proteinuria). Blood pressure is 142/88 mmHg. She is asymptomatic with no signs of uremia. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has stage 3b CKD (eGFR 32 mL/min/1.73 m²) with hypertension but no proteinuria. The absence of albuminuria suggests either early hypertensive nephropathy or primary hypertension with incidental CKD. ## Rationale for Correct Answer **Key Point:** All patients with CKD and hypertension should receive an ACE inhibitor or ARB, regardless of albuminuria status. These agents reduce intraglomerular pressure and slow GFR decline. **High-Yield:** ACE inhibitors and ARBs are renoprotective through: - Efferent arteriole vasodilation (reduces glomerular hyperfiltration) - Reduction in proteinuria - Anti-inflammatory and anti-fibrotic effects - Cardiovascular protection **Clinical Pearl:** Even in non-proteinuric CKD, RAAS inhibition slows progression. The absence of albuminuria does not exclude the benefit of ACE inhibitors or ARBs. ## Management Approach for Non-Proteinuric CKD with Hypertension | Finding | Implication | Action | | --- | --- | --- | | eGFR 30–44, no proteinuria, hypertension | Early CKD, likely hypertensive nephropathy | Start ACEi/ARB, optimize BP to <130/80 | | eGFR 30–44, proteinuria | Advanced CKD with renal disease | ACEi/ARB + SGLT2i (if DM) + BP control | | eGFR <15 | Stage 5 CKD | Prepare for RRT | ## Decision Tree for CKD Management ```mermaid flowchart TD A[eGFR 30-44 + HTN]:::outcome --> B{Proteinuria present?}:::decision B -->|No| C[Start ACEi/ARB for renoprotection]:::action B -->|Yes| D[Start ACEi/ARB + optimize BP]:::action C --> E[Recheck eGFR in 2-4 weeks]:::action D --> E E --> F{eGFR stable or improved?}:::decision F -->|Yes| G[Continue therapy, monitor q3-6 mo]:::action F -->|No| H[Assess adherence, consider RAS testing]:::action ``` ## Why Recheck eGFR in 2–4 Weeks? ACE inhibitors and ARBs may cause a transient 10–30% drop in eGFR due to reduced glomerular hyperfiltration. This is expected and not harmful. Persistent decline beyond 30% warrants investigation for renal artery stenosis or other complications.