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    Can Hypertension be Treated Safely in Chronic Kidney Disease?

    In a recent article on collaboration among specialties in treating patients with hypertension complicated by a variety of comorbidities, we explored medication choices available in the settings of chronic kidney disease (CKD), diabetes, and heart disease.1 In that series of short quizzes on the selection of antihypertensive medication, the emphasis was on the benefits a specific blood pressure agent might extend to a comorbidity (ACEI or ARBs in patients with heart failure, diabetes, and proteinuria, for example) as well as the potential adverse effect the antihypertensive might have on a specific comorbid disease (eg, metoprolol can increase insulin resistance in diabetics with hypertension and ACEIs/ARBs can worsen renal function or cause hyperkalemia).

    Let’s narrow the focus here to hypertension and CKD alone and test your knowledge of the current science and clinical medicine.

    Strict blood pressure control in the Modification of Diet in Renal Disease (MDRD) and African American Study of Kidney Disease and Hypertension (AASK) trials decreased the risk of death in the CKD population.2 In the NHANES II Study, a GFR <70 cc/min was associated with a higher adjusted risk of cardiovascular death.3 A prominent cardiovascular risk factor in the CKD population is hypertension. Three multiple choice questions will feature 3 important subtopics within the CKD-hypertension spectrum.

    Should we stop ACEIs/ARBs in CKD stages 4 and 5?

    ACEIs and ARBs are frequently prescribed for patients with hypertension and CKD, especially those with accompanying diabetes, proteinuria and/or heart failure. That said, did you know that there are no studies demonstrating the benefits of ACEI or ARB therapy in reducing cardiovascular events in persons with advanced CKD not on dialysis?4 Furthermore administration of ACEI-ARBS can interfere with renal autoregulation leading to a further decline in GFR.4 Discontinuation of ACEI/ARBs in advanced CKD may prevent episodes of acute renal failure that can lead to earlier dialysis initiation.4

    1. Which is the best single answer from the choices below for the question: Should ACEI/ARBS be stopped in advanced CKD?

    A. One study demonstrated a nephroprotective effect from ACEIs/ARBs across minimal to severe proteinuria in persons with CKD.

    B. If ACEI/ARB therapy in the CKD demographic is beneficial, using both classes will likely confer additional protections.

    C. It is unclear presently as to whether ACEI/ARBS have positive or negative effects in advanced CKD.

    D. There are currently no studies underway to address this important question.

    Answer and Discussion>>

     

    Gregory W. Rutecki, MD
    Dr Rutecki is with the Cleveland Clinic National Consultation Service.

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