What are the guidelines for initial treatment of hypertension (HTN) in a patient with unknown renal function?

From the Guidelines

For initial treatment of hypertension in a patient with unknown kidney function, start with a thiazide diuretic or a calcium channel blocker, as these medications are generally safe and effective first-line options when kidney function is unknown. According to the 2017 American College of Cardiology/American Heart Association hypertension guideline 1, thiazide diuretics (especially chlorthalidone) and calcium-channel blockers are the preferred options for first-line therapy in most adults because of their efficacy.

Before initiating treatment, it is essential to obtain baseline laboratory tests, including serum creatinine, estimated glomerular filtration rate (eGFR), electrolytes, and urinalysis to assess kidney function. Key considerations for initial treatment include:

• Thiazide diuretics, such as hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily
• Calcium channel blockers, such as amlodipine 5-10 mg daily
• The goal of treatment is to achieve a blood pressure target of less than 130/80 mm Hg, as recommended by the guideline 1

If the patient has significant proteinuria or reduced kidney function once results return, consider switching to or adding an ACE inhibitor (like lisinopril 10-40 mg daily) or an ARB (such as losartan 25-100 mg daily), as these medications offer renoprotective effects 1. However, it is crucial to avoid combining ACE inhibitors with ARBs due to increased adverse effects. Additionally, start with lower doses in elderly patients or those at risk for orthostatic hypotension. Monitor kidney function and electrolytes within 1-2 weeks after starting therapy, especially if ACE inhibitors or ARBs are used, as these can cause acute kidney injury in patients with renal artery stenosis or severe chronic kidney disease.

From the FDA Drug Label

DOSAGE & ADMINISTRATION 2. 1 Hypertension Initial Therapy in adults: The recommended initial dose is 10 mg once a day. Pediatric Patients 6 years of age and older with hypertension For pediatric patients with glomerular filtration rate > 30 mL/min/1.73m2, the recommended starting dose is 0. 07 mg per kg once daily (up to 5 mg total). Lisinopril tablets are not recommended in pediatric patients < 6 years or in pediatric patients with glomerular filtration rate < 30 mL/min/1.73m2

The initial treatment of hypertension (HTN) in patients with unknown kidney function is to start with a dose of 10 mg once a day for adults. For pediatric patients, the dose is 0.07 mg per kg once daily (up to 5 mg total), but only if the glomerular filtration rate is > 30 mL/min/1.73m2. Caution should be exercised when treating patients with unknown kidney function, as the drug label does not provide explicit guidelines for this scenario. In patients with unknown kidney function, it is recommended to exercise caution and consider alternative treatment options or monitor kidney function before initiating treatment with lisinopril 2.

From the Research

Initial Treatment of Hypertension in Patients with Unknown Kidney Function

• The initial treatment of hypertension in patients with unknown kidney function should focus on reducing blood pressure while also considering the potential renoprotective effects of certain medications 3, 4, 5, 6, 7.
• Angiotensin II receptor antagonists, such as losartan, have been shown to have renoprotective effects in patients with chronic kidney disease and hypertension, independent of their antihypertensive action 3.
• Calcium channel blockers, such as amlodipine, benidipine, and cilnidipine, can also be effective in reducing blood pressure and proteinuria in patients with hypertension and chronic kidney disease 4, 5, 6.
• The choice of initial treatment should be based on the individual patient's characteristics, including the presence of proteinuria, diabetes, and other comorbidities 5, 7.
• Ramipril, an angiotensin-converting enzyme (ACE) inhibitor, has been shown to retard renal disease progression in patients with hypertensive renal disease and proteinuria, and may offer benefit to patients without proteinuria 7.

Considerations for Patients with Proteinuria

• Patients with proteinuria should be treated with medications that have renoprotective effects, such as ACE inhibitors or angiotensin II receptor antagonists 3, 7.
• Calcium channel blockers, such as benidipine and cilnidipine, may also be effective in reducing proteinuria in patients with hypertension and chronic kidney disease 4, 5, 6.
• The goal of treatment should be to reduce proteinuria and slow the progression of renal disease, in addition to controlling blood pressure 3, 7.

Monitoring and Follow-up

• Patients with hypertension and unknown kidney function should be monitored regularly for changes in blood pressure, proteinuria, and renal function 3, 4, 5, 6, 7.
• The treatment plan should be adjusted as needed to achieve optimal blood pressure control and renoprotection 3, 7.