What treatment is indicated for a patient with impaired renal function, metabolic acidosis, and hypertension?

From the Guidelines

The patient with impaired renal function, metabolic acidosis, and hypertension should be started on an ACE inhibitor or an angiotensin receptor blocker (ARB) to control blood pressure and reduce proteinuria, with a goal of achieving a blood pressure of less than 130/80 mmHg. This recommendation is based on the most recent and highest quality study, which suggests that ACE inhibitors or ARBs are the preferred first-line treatment for hypertension in patients with diabetes and kidney disease 1. The use of these agents has been shown to reduce cardiovascular events and slow the progression of kidney disease.

Key Considerations

• The patient's impaired renal function and metabolic acidosis require careful consideration when selecting an antihypertensive agent, with a focus on agents that are renally safe and effective in reducing proteinuria.
• The patient's blood pressure should be closely monitored, with a goal of achieving a blood pressure of less than 130/80 mmHg, as recommended by the 2018 standards of medical care in diabetes 1.
• In addition to medication, the patient should follow a low-sodium diet, maintain adequate hydration, and avoid nephrotoxic medications, including NSAIDs.
• Regular monitoring of kidney function and electrolytes is essential, particularly 1-2 weeks after starting the ACE inhibitor or ARB.

Treatment Options

• ACE inhibitors, such as lisinopril, or ARBs, such as losartan, are recommended as first-line treatment for hypertension in patients with kidney disease 1.
• The choice of agent should be based on the patient's individual characteristics, including their renal function, blood pressure, and presence of proteinuria.
• Combination therapy with multiple antihypertensive agents may be necessary to achieve blood pressure goals, as recommended by the 2007 guidelines for the management of arterial hypertension 1.

From the FDA Drug Label

5.3 Impaired Renal Function Monitor renal function periodically in patients treated with lisinopril. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system.

Lisinopril may be used to treat hypertension in patients with impaired renal function, but it is crucial to monitor renal function periodically. However, the presence of metabolic acidosis is not directly addressed in the provided drug label as a factor to consider when treating with lisinopril. The use of lisinopril in patients with impaired renal function requires careful consideration, especially in those with conditions that may depend on the renin-angiotensin system, such as renal artery stenosis or severe congestive heart failure. It is essential to weigh the potential benefits and risks of using lisinopril in patients with impaired renal function, metabolic acidosis, and hypertension, and to closely monitor their condition. 2

From the Research

Treatment for Impaired Renal Function, Metabolic Acidosis, and Hypertension

• The treatment for a patient with impaired renal function, metabolic acidosis, and hypertension should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 3.
• First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern that includes low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption 3.
• For patients with chronic kidney disease and proteinuria, treatment should include an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) plus a thiazide diuretic or a calcium channel blocker 4.
• In patients with renal impairment, lower dosages of ACEIs may be necessary, and caution should be used when administering ACEIs with diuretics, nifedipine, or agents that may increase concentrations of potassium 5.
• The choice of add-on therapy to a renin-angiotensin system blocker for treating hypertension in patients with renal disease may be either hydrochlorothiazide or a calcium channel blocker, depending on the individual patient's needs and response to treatment 6.

Considerations for Treatment

• The decision to initiate antihypertensive medication should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 3.
• The BP-lowering effects of individual lifestyle components are partially additive and enhance the efficacy of pharmacologic therapy 3.
• Patients with heart failure with reduced ejection fraction should be treated initially with a beta blocker and an ACEI or ARB, followed by add-on therapy with a mineralocorticoid receptor antagonist and a diuretic based on volume status 4.
• In black patients, at least one agent should be a thiazide diuretic or a calcium channel blocker 4.