From the Guidelines
KDIGO recommends starting RASI therapy, either ACEI or ARB, as first-line treatment for patients with high blood pressure and CKD, particularly those with severely increased albuminuria. The choice of initial therapy is based on evidence that renin–angiotensin system inhibitors (RASI) reduce both cardiovascular event rates and kidney end points among patients with CKD 1. Specific medications include ACE inhibitors such as lisinopril, enalapril, ramipril, or ARBs such as losartan, valsartan, or irbesartan. These medications should be started at a lower dose and titrated upward as tolerated while monitoring kidney function and potassium levels.
- The strength of evidence varies according to the presence or absence of diabetes and of proteinuria, with strong evidence for benefit in the CKD subpopulation with low eGFR and severely increased albuminuria 1.
- Meta-analyses suggest effect modification by proteinuria for kidney outcomes, with a gradation of evidence for benefit from strong in the CKD subpopulation with low eGFR and severely increased albuminuria to weak or absent in the subpopulation with normal eGFR without albuminuria 1.
- The Work Group believed that the cardiovascular and survival benefits of intensive BP control outweighed the observed increases in risks for hyperkalemia, hypokalemia, and acute kidney injury 1.
- It is essential to monitor serum creatinine and potassium levels within 2-4 weeks of initiation or dose adjustment, as a rise in creatinine up to 30% from baseline is acceptable and often indicates effective blockade of the renin-angiotensin system.
From the Research
KDIGO Recommendations for ACE/ARBs in CKD
- The Kidney Disease Improving Global Outcomes (KDIGO) classifications are widely adopted for the recognition and management of chronic kidney disease (CKD) 2.
- According to the available evidence, there is no specific mention of KDIGO suggesting first-line ACE/ARBs for CKD 2, 3, 4, 5, 6.
- However, ACE inhibitors and angiotensin receptor blockers (ARBs) are recommended for the treatment of CKD, particularly for patients with hypertension and albuminuria 3, 4, 6.
- The choice of ACE inhibitor or ARB may depend on individual patient factors, such as comorbidities and potential side effects 4, 6.
- Some studies suggest that ACE inhibitors, such as benazepril and trandolapril, and ARBs, such as losartan, may be effective in reducing proteinuria and slowing the progression of CKD 2, 4.
- However, the evidence is not sufficient to determine the effectiveness of ACEi or ARB in patients with stage 1 to 3 CKD who do not have diabetes mellitus (DM) 2.