From the Guidelines
For a patient with a GFR of 28, it is recommended to use ACE inhibitors or ARBs as first-line blood pressure medications, with careful monitoring of renal function and potassium levels, as stated in the 2019 guideline from the American Heart Association and the Heart Failure Society of America 1. When managing blood pressure in patients with moderate to severe kidney disease, as indicated by a GFR of 28, the primary goal is to control blood pressure while protecting kidney function.
- Medications such as lisinopril (10-40 mg daily), enalapril (5-40 mg daily), or losartan (25-100 mg daily) are commonly prescribed for this purpose, as they not only control blood pressure but also reduce pressure within the kidney's filtering units and decrease protein leakage.
- Dosing should be initiated at a low level and gradually increased, with close monitoring of kidney function and potassium levels, to minimize the risk of adverse effects.
- Additionally, diuretics like furosemide (20-80 mg daily), as mentioned in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1, may be added to manage fluid retention, which is often a concern in patients with reduced kidney function.
- Calcium channel blockers, such as amlodipine (5-10 mg daily), are also suitable options because they do not typically worsen kidney function.
- Regular monitoring of blood pressure, kidney function, and electrolytes is crucial, with a target blood pressure usually below 130/80 mmHg.
- It is also important to note that medication adjustments may be necessary as kidney function changes, and combining multiple medications at lower doses can often provide better blood pressure control with fewer side effects, as suggested by the guideline 1.
From the FDA Drug Label
The pharmacokinetics of amlodipine are not significantly influenced by renal impairment. Patients with renal failure may therefore receive the usual initial dose The answer is: Amlodipine can be used in patients with a GFR of 28, as the pharmacokinetics of the drug are not significantly influenced by renal impairment.
- No dose adjustment is required for patients with renal failure. 2
From the Research
Blood Pressure Management for GFR of 28
- The management of blood pressure in patients with a glomerular filtration rate (GFR) of 28 requires careful consideration of the potential effects of different antihypertensive agents on renal function 3, 4.
- ACE inhibitors, such as ramipril, have been shown to have a renoprotective effect in patients with chronic renal disease, and may be a suitable option for patients with a GFR of 28 3.
- Calcium channel blockers, such as felodipine, may also be effective in reducing blood pressure in patients with renal disease, but may not provide the same level of renoprotection as ACE inhibitors 3, 5, 4.
- The combination of an ACE inhibitor and a calcium channel blocker may be a useful therapeutic option in patients with renal disease and hypertension, as it may provide better blood pressure control and slower progression of renal disease compared to either agent alone 3.
- In patients with a GFR of less than 30 mL/min/1.73 m2, nondihydropyridine calcium channel blockers may be associated with increased hospitalizations due to poor heart rate control, and the effects of these drugs on renal function in this population require further investigation 6.
Antihypertensive Agents and Renal Function
- The choice of antihypertensive agent in patients with a GFR of 28 should be based on the individual patient's clinical characteristics and medical history, as well as the potential effects of the agent on renal function 7, 5, 4.
- Beta blockers and diuretics may also be used in the management of hypertension in patients with renal disease, but may not provide the same level of renoprotection as ACE inhibitors or calcium channel blockers 7, 6.
- The use of combination antihypertensive therapy, including agents from different pharmacologic classes, may be necessary to achieve adequate blood pressure control in patients with renal disease 7.