Management of CKD in a Patient with Cardiovascular Disease

A 62-year-old man with a history of coronary artery disease, hypertension, and stage IV chronic kidney disease from presumed long-standing hypertension is seen for routine follow up. He feels well and denies any chest pain, urinary symptoms, or lower extremity edema.

On physical examination, the patient's blood pressure is 120/72 mm Hg, heart rate 64/min. His cardiac examination is normal, lungs are clear and he has no peripheral edema. Laboratories are notable for a serum creatinine of 2.4 mg/dL (eGFR 27 mL/min/1.73m2), potassium 5.2 mEq/L, blood urea nitrogen 41 mg/dL. Urinalysis shows 1+ proteinuria and quantification reveals 250mg/g of albuminuria on a spot urine albumin to creatinine ratio. Medications include lisinopril 40mg daily, amlodipine 10mg daily, aspirin 81mg daily and metoprolol 25mg BID. He has no history of diabetes, heart failure, urinary retention or recurrent urinary tract infections.

What is the next best step in management to reduce his risk of progression to end stage kidney disease?

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