What is the best blood pressure (BP) medication for a patient with a history of Acute Kidney Injury (AKI)?

From the Guidelines

The best blood pressure medication for a patient with a history of Acute Kidney Injury (AKI) is typically an Angiotensin-Converting Enzyme (ACE) inhibitor or an Angiotensin II Receptor Blocker (ARB). Medications such as lisinopril (ACE inhibitor, starting at 5-10mg daily) or losartan (ARB, starting at 25-50mg daily) are often recommended as first-line options, as supported by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. These medications are preferred because they provide renoprotective effects by reducing intraglomerular pressure and proteinuria, which helps preserve kidney function over time. However, dosing should start low and be titrated gradually with close monitoring of kidney function and potassium levels, especially in the first few weeks of treatment. It's crucial to monitor serum creatinine and potassium 1-2 weeks after initiation or dose changes.

Some key points to consider when using ACE inhibitors or ARBs in patients with a history of AKI include:

• They should not be discontinued for minor increases in serum creatinine (<30%), in the absence of volume depletion, as stated in the 2022 standards of medical care in diabetes 1.
• The maximally tolerated doses should be used, as low doses may not provide benefit, and outcome benefits on both mortality and slowed CKD progression have been demonstrated in people with diabetes who have an eGFR <30 mL/min/1.73 m2 1.
• If the patient has significant residual kidney dysfunction, calcium channel blockers like amlodipine (5-10mg daily) may be a safer alternative as they don't directly affect kidney hemodynamics.
• Diuretics may be necessary for volume control but should be used cautiously.

The medication choice should ultimately be individualized based on the cause of the patient's AKI, their current kidney function, comorbidities, and blood pressure goals, with regular monitoring to ensure the chosen medication isn't adversely affecting kidney recovery. Recent studies, such as those published in 2022, emphasize the importance of timely identification and treatment of AKI, as well as the use of vasoconstrictors and albumin in the treatment of hepatorenal syndrome-associated AKI 1. However, these studies do not directly impact the choice of blood pressure medication in patients with a history of AKI, and the primary consideration remains the use of ACE inhibitors or ARBs as first-line options.

From the FDA Drug Label

The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]). Treatment with losartan resulted in a 16% risk reduction in this endpoint (see Figure 4 and Table 4) Treatment with losartan also reduced the occurrence of sustained doubling of serum creatinine by 25% and ESRD by 29% as separate endpoints, but had no effect on overall mortality (see Table 4).

The best blood pressure medication for a patient with a history of Acute Kidney Injury (AKI) is losartan, as it has been shown to reduce the risk of doubling of serum creatinine and end-stage renal disease (ESRD) in patients with nephropathy 2.

• Key benefits of losartan include:
  • Reduced risk of doubling of serum creatinine by 25%
  • Reduced risk of ESRD by 29%
  • Reduced proteinuria by an average of 34%
  • Reduced rate of decline in glomerular filtration rate by 13%

From the Research

Blood Pressure Medication for Patients with a History of AKI

• The best blood pressure (BP) medication for a patient with a history of Acute Kidney Injury (AKI) is not explicitly stated in the provided studies, but some evidence suggests that angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may be beneficial in improving outcomes after AKI 3.
• ACEIs or ARBs have been associated with lower mortality in patients with AKI, but may also increase the risk of hospitalization for a renal cause 3.
• The use of ACEIs or ARBs in patients with AKI should be carefully considered, taking into account the individual patient's risk factors and medical history 3.
• It is essential to monitor patients with AKI closely for renal-specific complications, regardless of the BP medication used 3.
• The management of AKI typically involves control of the underlying cause, achievement and maintenance of euvolemia, nutritional optimization, blood glucose control, and pharmacotherapy 4, 5, 6, 7.

Considerations for BP Medication in AKI Patients

• Patients with AKI are at an increased long-term risk of death, and effective strategies to improve outcomes are unknown 3.
• The choice of BP medication in patients with AKI should be individualized, taking into account the patient's underlying medical conditions, kidney function, and other factors 4, 5, 6, 7.
• Further research is needed to determine the optimal BP medication for patients with a history of AKI 3.