From the Guidelines
The preferred antihypertensive medication for a patient with Chronic Kidney Disease (CKD) stage three is an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB), as they provide renoprotective effects and effectively lower blood pressure. According to the most recent and highest quality study, 1, the Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline recommends starting renin-angiotensin-system inhibitors (RASi), such as ACEi or ARB, for people with high blood pressure, CKD, and severely increased albuminuria.
Some key points to consider when prescribing these medications include:
- Starting with a low dose, such as lisinopril (ACEI) 5-10 mg daily or losartan (ARB) 25-50 mg daily
- Monitoring serum creatinine and potassium levels within 1-2 weeks of starting therapy to detect potential acute kidney injury or hyperkalemia
- Aiming for a blood pressure target of <130/80 mmHg, as recommended by the American College of Cardiology/American Heart Association guideline 1
- Considering the addition of a calcium channel blocker or a diuretic as second-line therapy if blood pressure targets are not achieved with a single agent
It's also important to note that the combination of ACEi, ARB, and direct renin inhibitor therapy should be avoided in patients with CKD, as recommended by the KDIGO 2021 guideline 1. Additionally, the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) consensus report 1 supports the use of ACEi or ARB as the preferred first-line agent for blood pressure treatment in patients with diabetes, hypertension, and albuminuria.
From the Research
Antihypertensive Medications for CKD Stage Three Patients
The preferred antihypertensive medication for a patient with Chronic Kidney Disease (CKD) stage three is a topic of discussion among medical professionals.
- Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are recommended as a first-line antihypertensive approach in patients with chronic kidney disease 2, 3, 4.
- These medications have beneficial effects on proteinuria and declining renal function that appear to be mediated by factors additional to their effects on blood pressure 2.
- The addition of diuretics and calcium channel antagonists to RAS inhibitor therapy is also considered to be a rational strategy to reduce blood pressure and preserve renal function 2, 3.
- 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 RAAS blocker 3.
- Diuretics are commonly used and represent the cornerstone in the management of CKD patients 3.
Blood Pressure Goals for CKD Stage Three Patients
- The blood pressure goal for patients with CKD stage three is less than 130/80 mmHg 3, 4.
- Achieving this goal may require lifestyle modifications and multiple antihypertensive medications 3.
- Intensive blood pressure control has been shown to slow the progression of kidney disease and reduce the risk of cardiovascular events 3.
Treatment Options for CKD Stage Three Patients
- ACE inhibitors and ARBs are the preferred treatment options for CKD stage three patients 2, 3, 4.
- Direct renin inhibition, such as aliskiren, may also be a useful treatment option for CKD patients, either alone or in combination with ARBs 5.
- The choice of treatment should be individualized based on the patient's specific needs and medical history 2, 3, 4.