Is candesartan (angiotensin II receptor antagonist) appropriate for a patient with impaired renal function (eGFR of 20ml/min) and hypertension (sitting blood pressure around 150/100 mmHg)?

From the Guidelines

For a patient with an eGFR of 20 ml/min on candesartan with a sitting BP of around 150/100, I would recommend dose reduction or consideration of an alternative antihypertensive medication, such as a loop diuretic like furosemide or bumetanide, as they are preferred diuretics in patients with symptomatic HF and moderate-to-severe CKD (eGFR <30 mL/min) 1.

Key Considerations

• Candesartan should be used cautiously in severe renal impairment (eGFR <30 ml/min) as it can worsen kidney function and cause hyperkalemia, particularly in patients on K+ supplements or K+-sparing drugs 1.
• The current dose should be reduced by 50% or to the lowest effective dose, and close monitoring of renal function, potassium levels, and blood pressure is essential.
• Given the inadequate blood pressure control (150/100), additional or alternative antihypertensive therapy may be needed, such as a calcium channel blocker like amlodipine, which can be used if required, but with caution in patients with HFrEF 1.

Alternative Therapies

• Consider adding a loop diuretic like furosemide (20–80 mg/day) or bumetanide (0.5–2 mg/day), which are preferred diuretics in patients with symptomatic HF and moderate-to-severe CKD (eGFR <30 mL/min) 1.
• Angiotensin receptor blockers like candesartan can cause acute kidney injury by reducing efferent arteriolar tone, decreasing glomerular filtration pressure, and this risk increases in patients with pre-existing renal impairment, especially if they have renal artery stenosis or are volume depleted 1.

Monitoring

• Regular monitoring of serum creatinine, eGFR, and potassium levels is crucial, particularly after dose adjustments, to prevent hyperkalemia and worsening kidney function 1.

From the FDA Drug Label

In hypertensive patients with renal insufficiency, serum concentrations of candesartan were elevated. After repeated dosing, the AUC and Cmax were approximately doubled in patients with severe renal impairment (creatinine clearance <30 mL/min/1. 73m2) compared to patients with normal kidney function. No dose adjustment is required in patients with mild CrCL 60-90 ml/min) or moderate (CrCL 30-60 ml/min) renal impairment Safety and effectiveness of candesartan cilexetil and hydrochlorothiazide tablets in patients with severe renal impairment (CrCL ≤30 ml/min) have not been established.

The patient's eGFR of 20ml/min indicates severe renal impairment. When reviewing whether candesartan is appropriate for this patient, consider the following key points:

• Elevated serum concentrations: The patient may experience elevated serum concentrations of candesartan due to their renal insufficiency.
• Lack of established safety and effectiveness: The safety and effectiveness of candesartan cilexetil in patients with severe renal impairment (CrCL ≤30 ml/min) have not been established.
• Potential for increased risk: The patient's severe renal impairment may increase the risk of adverse effects associated with candesartan. Given the patient's sitting BP of around 150/100, it is essential to weigh the potential benefits of candesartan against the potential risks associated with their severe renal impairment. Consider alternative treatment options or close monitoring of the patient's condition and adjust the treatment plan as needed 2.

From the Research

Patient Considerations

When reviewing whether candesartan is appropriate for a patient with an eGFR of 20ml/min and a sitting blood pressure of around 150/100, several factors should be considered:

• The patient's kidney function, as indicated by their eGFR, is significantly impaired, which may affect the dosing and efficacy of candesartan 3, 4.
• The patient's blood pressure is elevated, which may require adjustment of their antihypertensive medication regimen, including candesartan 5, 6.
• The use of candesartan, an angiotensin II receptor blocker, may be beneficial in reducing blood pressure and slowing the progression of kidney disease, but its effectiveness may be influenced by the patient's underlying kidney function and other comorbidities 5, 6.

Medication Considerations

When evaluating the appropriateness of candesartan for this patient, consider the following:

• The potential benefits of candesartan in reducing blood pressure and slowing kidney disease progression, as well as its tolerability and potential interactions with other medications 5, 6.
• The possibility of adding a diuretic to the patient's medication regimen, as suggested by a study comparing the effectiveness of diuretics and calcium channel blockers on top of renin-angiotensin system inhibitors on chronic kidney disease progression and mortality 7.
• The importance of monitoring the patient's kidney function, blood pressure, and other relevant parameters to adjust their medication regimen as needed 3, 4.

Clinical Decision-Making

In making clinical decisions about the patient's medication regimen, consider the following:

• The patient's individual characteristics, such as their age, sex, and comorbidities, which may influence the effectiveness and tolerability of candesartan 3, 4.
• The potential risks and benefits of continuing or adjusting the patient's medication regimen, including the use of candesartan and other antihypertensive agents 5, 6, 7.
• The importance of ongoing monitoring and evaluation to ensure that the patient's medication regimen is optimized and effective in managing their blood pressure and kidney disease 3, 4.