Antihypertensive medications for progressive kidney failure
What are the preferred antihypertensive medications for a patient with progressive kidney failure?
Multiple studies suggest that in CKD, particularly with increased urine protein excretion, an ACE inhibitor or ARB is the preferred antihypertensive medications (and perhaps direct renin inhibitors if ACE inhibitors or ARBs are not tolerated).
For a patient with proteinuria, BP reduction and urine protein excretion should be goals of therapy and used to titrate doses of either of these medication classes upward. Studies of ACE inhibitors and ARBs in patients with diabetes, human immunodeficiency virus (HIV)-associated nephropathy, and multiple other glomerular diseases demonstrate a benefit from the use of these agents in slowing the progression of kidney disease independent of their BP effects.
Due to their effects on glomerular hemodynamics, patients treated with ACE inhibitors and ARBs should have their serum creatinine and potassium levels monitored. Side effects include hyperkalemia and acute kidney injury (AKI). Late-onset kidney failure from angiotensin blockade has been described.
A study of older patients who had significant worsening of creatinine with angiotensin blockade (>25% increase in serum creatinine) found that once angiotensin blockade was stopped, most showed improvement or stabilization in kidney function. Whether these changes represent a transient hemodynamic effect or true progression of their underlying CKD needs further investigation.
