What is the recommended treatment for a patient with Hypertension (HTN), metastatic bladder cancer, Impaired renal function (eGFR of 49) and elevated Albumin to Creatinine Ratio (ACR of 16.6)?

From the Guidelines

For a patient with hypertension, metastatic bladder cancer, impaired renal function (eGFR 49), and elevated albumin-to-creatinine ratio (ACR 16.6), I strongly recommend an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) as first-line antihypertensive therapy, as supported by the most recent and highest quality study 1. This approach is based on the patient's clinical presentation, where the use of ACE inhibitors or ARBs is preferred for managing hypertension in patients with chronic kidney disease (CKD) and albuminuria, due to their renoprotective effects and ability to reduce proteinuria. The patient's moderately reduced kidney function, as indicated by an eGFR of 49, and elevated ACR of 16.6, necessitate careful consideration of the potential benefits and risks of different antihypertensive therapies. Key considerations in managing this patient include:

• Monitoring blood pressure closely and adjusting therapy as needed to achieve individualized blood pressure targets, generally aiming for <130/80 mmHg if tolerated.
• Regular monitoring of renal function, electrolytes, and proteinuria to adjust therapy as needed, particularly in the context of cancer treatment.
• Coordination with the patient's oncology team, as some cancer therapies may impact blood pressure control and kidney function. Specific options for ACE inhibitors or ARBs include lisinopril starting at 5-10 mg daily or losartan 25-50 mg daily, with dose adjustments based on blood pressure response and renal function monitoring. If additional blood pressure control is needed, a long-acting calcium channel blocker like amlodipine 5-10 mg daily could be added, as suggested by earlier guidelines 1. However, the most recent and highest quality evidence 1 supports the use of ACE inhibitors or ARBs as the primary approach, given their benefits in reducing progression of CKD and cardiovascular events. Diuretics should be used cautiously due to the patient's reduced renal function, and their use should be carefully considered in the context of the patient's overall clinical presentation and response to initial therapy. Overall, the treatment approach should prioritize the patient's morbidity, mortality, and quality of life outcomes, with careful consideration of the potential interactions between antihypertensive therapy and cancer treatment.

From the Research

Treatment Considerations for Metastatic Bladder Cancer with Hypertension and Impaired Renal Function

• The patient's metastatic bladder cancer, hypertension (HTN), impaired renal function (eGFR of 49), and elevated Albumin to Creatinine Ratio (ACR of 16.6) require careful consideration in determining the optimal treatment approach 2, 3, 4.
• Chemotherapy remains a mainstay of treatment for metastatic bladder cancer, but the patient's impaired renal function may impact the choice of chemotherapeutic agents and dosing 2.
• Targeted molecular therapeutics, such as enfortumab vedotin and sacituzumab govitecan, have shown promise in treating metastatic bladder cancer, with impressive response rates in heavily pre-treated patients 5.
• Immune checkpoint inhibitors (ICIs), including pembrolizumab, nivolumab, and atezolizumab, have been approved for the treatment of metastatic urothelial carcinoma, but their effectiveness may be influenced by factors such as PD-L1 expression and the patient's overall health status 6.

Management of Hypertension in Cancer Patients

• Hypertension is a common comorbidity in cancer patients, and its management is crucial to reduce the risk of cardiovascular complications 3, 4.
• The selection of antihypertensive agents should take into account the patient's treatment-specific morbidities and target organ injury, as well as potential interactions with cancer therapies 4.
• Home blood pressure monitoring can be a useful tool for longitudinal blood pressure monitoring and titration of antihypertensive medications in cancer patients 4.

Renal Function Considerations

• The patient's impaired renal function (eGFR of 49) and elevated ACR (16.6) indicate a need for careful monitoring and management of renal function during treatment 2, 4.
• The choice of chemotherapeutic agents and dosing should be adjusted according to the patient's renal function to minimize the risk of nephrotoxicity 2.