What is the best management approach for a patient with impaired renal function and hypertension currently on lisinopril (Angiotensin-Converting Enzyme inhibitor) with a blood pressure of 144/69 mmHg?

From the Guidelines

The most appropriate management for this patient is to continue current medical therapy, as the current systolic blood pressure is close to the target of <140 mmHg, and the patient has impaired renal function, which requires careful monitoring and potential dosage adjustments of the ACE inhibitor lisinopril. The patient's blood pressure is 144/69 mmHg, which is close to the target blood pressure of <140/90 mmHg, as recommended by the NHLBI guidelines 1. Considering the patient's impaired renal function, with an estimated glomerular filtration rate (eGFR) of 34 mL/min/1.73 m2, it is essential to continue the ACE inhibitor therapy, as it provides renoprotective effects by reducing intraglomerular pressure and proteinuria, potentially slowing the progression of kidney disease 1. Some key points to consider in the management of this patient include:

• Monitoring renal function and potassium levels closely, as ACE inhibitors can cause hyperkalemia and worsening renal function, especially in patients with impaired renal function 1.
• Optimizing the lisinopril dose if tolerated, or considering the addition of a complementary agent, such as a calcium channel blocker, if the blood pressure remains above the target range.
• Emphasizing lifestyle modifications, including sodium restriction (<2g/day), regular physical activity, and weight management, as important complementary strategies to control blood pressure and slow the progression of kidney disease 1. It is also important to note that the patient's current medications, including glipizide, rosuvastatin, and low-dose aspirin, should be continued, and their potential effects on renal function and blood pressure should be monitored closely. Overall, the goal of management is to control blood pressure, slow the progression of kidney disease, and reduce the risk of cardiovascular morbidity and mortality, while carefully monitoring the patient's renal function and potential side effects of therapy.

From the FDA Drug Label

Use with diuretics in adults If blood pressure is not controlled with lisinopril tablets alone, a low dose of a diuretic may be added (e.g., hydrochlorothiazide, 12. 5 mg). 2. 4 Dose in Patients with Renal Impairment No dose adjustment of lisinopril tablets is required in patients with creatinine clearance > 30 mL/min. In patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, reduce the initial dose of lisinopril tablets to half of the usual recommended dose i.e., hypertension, 5 mg;

The patient's current blood pressure is 144/69 mmHg, and the estimated glomerular filtration rate is 34 mL/min/1.73 m2. No dose adjustment of lisinopril is required since the creatinine clearance is > 30 mL/min. The most appropriate management approach is to continue current medical therapy and monitor the patient's blood pressure and renal function. Key points:

• The patient's blood pressure is not adequately controlled, but the current dose of lisinopril does not need to be adjusted based on renal function.
• Adding a diuretic, such as chlorthalidone or hydrochlorothiazide, may be considered to help control blood pressure.
• The patient's renal function and blood pressure should be closely monitored. The best answer is D. 2

From the Research

Patient Management

The patient is a 70-year-old woman with hypertension, peripheral vascular disease, hyperlipidemia, and type 2 diabetes mellitus, currently on lisinopril, glipizide, rosuvastatin, and low-dose aspirin. Her blood pressure is 144/69 mm Hg, and she has impaired renal function with an estimated glomerular filtration rate of 34 mL/min/1.73 m2.

Current Medications and Renal Function

• Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that is effective in lowering blood pressure and is well tolerated 3, 4.
• The patient's renal function is impaired, with a creatinine level of 1.4 mg/dL and an estimated glomerular filtration rate of 34 mL/min/1.73 m2.
• Lisinopril is excreted unchanged in the urine, and significant accumulation occurs in patients with severe renal impairment (creatinine clearance less than or equal to 30 ml/min) 3.

Treatment Options

• Adding chlorthalidone, a thiazide-like diuretic, may be considered to enhance the antihypertensive effect of lisinopril 5, 4.
• Switching lisinopril to ramipril, another ACE inhibitor, may not provide additional benefits and is not recommended without a specific indication.
• Adding prazosin, an alpha-blocker, is not typically used as a first-line treatment for hypertension and may not be necessary in this case.
• Continuing current medical therapy and monitoring the patient's blood pressure and renal function may be the most appropriate management approach, given the patient's complex medical history and current medication regimen.

Considerations

• The patient's blood pressure is currently 144/69 mm Hg, which is above the recommended target of <130/80 mm Hg for adults with hypertension and diabetes 5.
• The patient's renal function is impaired, and careful monitoring of her kidney function and electrolyte levels is necessary when using ACE inhibitors like lisinopril 3, 6.
• The patient's medical history and current medication regimen should be carefully considered when making any changes to her treatment plan.

Best Course of Action

Based on the available evidence, the best course of action would be to continue current medical therapy and monitor the patient's blood pressure and renal function closely, as there is no clear indication to change the current treatment plan 5, 4, 7.