This recommendation is based on observational data and subgroup and post hoc analyses, hence the grade of 2D. 3.5: We recommend that an ARB or ACE-I be used in non-diabetic adults with CKD ND and urine albumin excretion 4300 mg per 24 hours (or equivalent*) in whom treatment with BP-lowering drugs is indicated. (1B) *Approximate equivalents for albumin excretion rate per 24 hours expressed as protein excretion rate per 24 hours, albumin/creatinine ratio, protein/creatinine ratio, and protein reagent strip results are given in Table 1, Chapter 1. RATIONALE K Urine albumin excretion 4300 mg per 24 hours ( macroalbuminuria ) is a risk factor for CVD and for CKD progression. K In RCTs involving patients with CKD and urine albumin excretion 4300 mg per 24 hours, ARBs or ACE-Is reduce the risks of hard outcomes such as the doubling of SCr level, kidney failure, or death. Patients with macroalbuminuria are at very high risk for both progression of CKD and development of CVD.18,162,163 Kidney disease. Several trials have demonstrated a benefit, in patients with macroalbuminuria, of ACE-Is or ARBs over either placebo or other agents, in reducing the risk of macroalbuminuria, doubling of creatinine levels, and devel- opment of kidney failure (See Supplementary Tables 7 12 online). These trials include RCTs in patients with CKD of various causes, primarily glomerulonephritis,191 African-Americans and patients with advanced CKD (a A meta-analysis of in- dividual patient data from 11 RCTs compared antihyperten- sive regimens including ACE-Is to regimens without ACE-Is in 1860 patients with predominantly non-diabetic CKD. In adjusted analyses, ACE-Is were associated with a HR of 0.69 for kidney failure (95% CI 0.51 0.94) and 0.70 for the combined outcome of doubling of the baseline SCr concentration or kidney failure (95% CI 0.55 0.88). 