You didn’t mention the patient’s age and life expectancy. It’s important to know the risk factors, general health status, co-morbid conditions and life expectancy to make therapeutic decisions. It should be emphasized that the presence of microalbuminuria indicates increased cardiovascular (CV) risk, and reduction of other risk factors — including smoking cessation and control of lipids to target — ought to accompany efforts at blood pressure (BP) and glycemic control.

The mainstay of treatment in microalbuminuria is targeting blood pressure below 130/80. Treatment must include, if tolerated, an agent that inhibits the renin-angiotension-aldosterone system — either an angiotensin converting enzyme inhibitor or angiotensin receptor blockers (ARBs); and optimal diabetic control with targeting A_1C at < 0.07.

It appears from your statement that you’ve achieved the BP and glycemic targets in your patient with the use of an ARB and low dose diuretic. Because of increasing microalbuminuria, however, it’s important to ascertain that the blood pressure is indeed under control and we’re not dealing with masked hypertension. A 24-hr ambulatory blood pressure (ABPM) would be required to exclude this and to ascertain that the patient’s BP is under control and to exclude non-dipper state.

If any of these conditions are present, then further adjustment in BP medications is indicated. If the 24-hr ABPM indicates that the BP is under control along with the other CV risk factors — you have done your best to control microalbuminuria as per current recommendations, understanding that natural progression in some would continue despite optimal control of risk factors. As the patient has chronic kidney disease, monitoring of renal function at 2-3 month intervals for at least a year is also required to assess stability or progression of chronic kidney disease.

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