REVIEW
SHELDON HIRSCH, MD

CME CREDIT

Chief of Nephrology, Mercy Hospital and Michael Reese Hospital, Chicago, IL

An update on proteinuric chronic kidney disease: The dual-goal approach
■ ■ABSTRACT
Lowering both blood pressure and urinary albumin excretion to specific goals may slow the progression of proteinuric chronic kidney disease. However, this dualgoal approach needs to be validated prospectively.

W1hen angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type receptor blockers (ARBs) were intro-

■ ■KEY POINTS
Evidence is emerging that urinary albumin is toxic to the kidney. Lowering both blood pressure and urinary albumin excretion, as a means to prevent progressive renal disease, appears to require …ver más…

We also need to set a goal level of proteinuria, continually adjusting the renoprotective medicines until the goal is achieved. Although albumin has not been conclusively proven to be a renal toxin, targeting the reduction of proteinuria may also succeed if urinary albumin simply serves as a marker of the success of chronic kidney disease treatment and reflects prognosis. ■ A dUAL-gOAL ApprOACh In view of the observational and experimental evidence, many experts10,15–18 are advocating a dual-goal approach that stresses lowering both blood pressure and urinary protein (albumin) excretion. The recommended goal for systolic blood pressure is less than 120 to 125 mm Hg; the goal for proteinuria is less than 300 to 500 mg/24 hours,16,17,19 aiming to slow the decline in glomerular filtration rate to less than 2 mL/ min/year.11,20 The strategy of targeting both proteinuria and blood pressure has recently received further support. In a prospective randomized controlled study,21 nondiabetic patients with proteinuria received either an ACE inhibitor or