What is the best treatment approach for patients with kidney-related hypertension?

From the Guidelines

The best treatment approach for patients with kidney-related hypertension is to use a combination of medications and lifestyle modifications, with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) as first-line medications, as recommended by the most recent guidelines 1.

Key Considerations

• ACE inhibitors or ARBs are effective in lowering blood pressure and reducing proteinuria, and are recommended for patients with urinary albumin excretion >30 mg/day 1.
• Diuretics, such as thiazides or loop diuretics, may be added as second-line agents to help control blood pressure 1.
• Calcium channel blockers, such as amlodipine, may be added if blood pressure remains uncontrolled 1.
• Lifestyle modifications, including dietary sodium restriction to less than 2,300 mg daily, maintaining adequate hydration, limiting alcohol, avoiding NSAIDs, achieving a healthy weight, and regular physical activity, are crucial in managing kidney-related hypertension 1.

Medication Options

• ACE inhibitors: lisinopril (10-40 mg daily), enalapril (5-40 mg daily)
• ARBs: losartan (25-100 mg daily), valsartan (80-320 mg daily)
• Diuretics: hydrochlorothiazide (12.5-50 mg daily), furosemide (20-80 mg daily)
• Calcium channel blockers: amlodipine (5-10 mg daily)

Monitoring and Follow-up

• Regular monitoring of kidney function and electrolytes, especially when initiating or adjusting medications that affect the renin-angiotensin-aldosterone system 1.
• Blood pressure should be targeted to below 130/80 mmHg in most kidney patients 1.

From the FDA Drug Label

The beneficial effects of lisinopril in hypertension and heart failure appear to result primarily from suppression of the renin-angiotensin-aldosterone system. In patients with renovascular hypertension lisinopril has been shown to be well tolerated and effective in reducing blood pressure [see Warnings and Precautions (5. 3)].

The best treatment approach for patients with kidney-related hypertension is to use an ACE inhibitor like lisinopril, as it has been shown to be effective in reducing blood pressure in these patients by suppressing the renin-angiotensin-aldosterone system.

• Lisinopril is well-tolerated and effective in patients with renovascular hypertension.
• The treatment should be done under the guidance of a healthcare professional, taking into account the patient's overall health and medical history 2.

From the Research

Treatment Approach for Kidney-Related Hypertension

The treatment approach for patients with kidney-related hypertension involves a combination of lifestyle modifications and multiple antihypertensive medications.

• The updated hypertension guidelines recommend a blood pressure (BP) goal < 130/80 mmHg for patients with established chronic kidney disease (CKD) and/or diabetes with albuminuria 3.
• Lifestyle modifications, such as weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption, are recommended as first-line therapy for hypertension 4, 5, 6.
• Angiotensin-converting enzyme (ACE) inhibitors should be the drugs of first choice, followed by angiotensin II receptor blockers (ARBs) if the ACE inhibitor is not tolerated 3, 7.
• Non-dihydropyridine calcium channel blockers (CCBs) consistently reduce albuminuria and slow the decline in kidney function, while dihydropyridine CCBs should not be used as monotherapy in proteinuric CKD patients but always in combination with a renin-angiotensin-aldosterone system (RAAS) blocker 3, 7.
• Diuretics are commonly used and represent the cornerstone in the management of CKD patients, with the addition of other agents considered when treatment with primary agents has failed 3, 7.

Lifestyle Modifications

Lifestyle modifications are crucial in the treatment of hypertension and should be recommended to most hypertensive patients.

• The dietary approaches to stop hypertension (DASH) diet may be considered the most effective treatment for reducing blood pressure 5.
• Diet adaptation containing low sodium and alcohol restriction may be the most effective in reducing blood pressure, along with physical exercise and weight reduction 5.
• Lifestyle modifications should be tried first for patients with high-normal blood pressure or grade 1 hypertension without high risk factors, and can also enhance the effects of antihypertensive therapy in other patients 5, 6.

Antihypertensive Medications

The selection of antihypertensive therapy for patients with kidney-related hypertension should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk.

• ACE inhibitors and ARBs have beneficial effects on proteinuria and declining renal function that appear to be mediated by factors additional to their effects on blood pressure 7.
• The addition of diuretics and calcium channel antagonists to RAAS inhibitor therapy is considered a rational strategy to reduce blood pressure and preserve renal function 7.
• Manidipine, a third-generation dihydropyridine calcium channel antagonist, may be an excellent antihypertensive drug in combination with RAAS inhibitor treatment to normalize blood pressure and albumin excretion in patients with diabetes 7.