Maintaining the current antihypertensive regimen and a standard protein diet is appropriate in this patient to help slow progression of her chronic kidney disease (CKD).

Although earlier, small studies suggested that low protein diets may slow CKD progression, the landmark Modification of Diet in Renal Disease study did not detect a significant protective effect of protein-restricted diets in preventing progression of kidney disease. However, low protein diets may delay onset of symptomatic uremia in patients with late-stage CKD (stage G4/G5).

The eighth report from the Joint National Committee (JNC 8) recommends a target blood pressure of <140/90 mm Hg with ACE inhibitors or angiotensin receptor blockers as first-line agents for treatment of hypertension in patients with CKD. This patient currently meets this recommended goal with an ACE inhibitor as part of her regimen. Although previously recommended by several organizations, there are currently insufficient data to support targeting blood pressures lower than 140/90 mm Hg to prevent progression of kidney disease with the possible exception of patients with severe proteinuria (stage A3 or an albumin-creatinine ratio >300 mg/g), in which some randomized controlled trials have suggested the benefit of a lower blood pressure goal of <130/80 mm Hg.

Volume expansion may contribute to hypertension in CKD; therefore, maintaining normal volume status is important for long-term blood pressure control. Although the diuretic effect of thiazides becomes less effective as the glomerular filtration rate drops, often requiring a switch to a loop diuretic, this patient is clinically euvolemic and with adequate blood pressure control. Additionally, diuretics themselves do not alter progression of proteinuria or CKD. Therefore, there is no indication for switching diuretic therapy in this patient.