Should the antihypertensive regimen be changed for a 55-year-old African-American female with type 2 diabetes and impaired renal function, currently on hydrochlorothiazide (HCTZ) and lisinopril?

Antihypertensive Management for African-American Female with Declining Kidney Function and Diabetes

The current antihypertensive regimen should be modified by continuing lisinopril but replacing hydrochlorothiazide with a loop diuretic due to the declining kidney function (eGFR 38 mL/min/1.73m²). 1, 2

Assessment of Current Situation

This 55-year-old African-American female presents with:

• Rapidly declining kidney function (eGFR 38, creatinine 1.6)
• Type 2 diabetes
• Current medications: hydrochlorothiazide 50mg daily and lisinopril 20mg daily

Recommended Medication Changes

1. Continue ACE inhibitor therapy:

   • Maintain lisinopril 20mg daily
   • ACE inhibitors are recommended as first-line agents for patients with diabetes and CKD 1, 2
   • Lisinopril provides renoprotection by reducing intraglomerular pressure and proteinuria 3

2. Replace hydrochlorothiazide with loop diuretic:

   • Discontinue hydrochlorothiazide 50mg
   • Add furosemide 40mg daily or equivalent loop diuretic
   • Thiazide diuretics lose effectiveness when eGFR falls below 30-40 mL/min/1.73m² 2

3. Consider adding a third agent if BP remains uncontrolled:

   • Add a dihydropyridine calcium channel blocker (e.g., amlodipine 5-10mg daily) if BP remains above target 1, 2
   • Most patients with CKD require multiple agents (3-4) to reach target BP 1

Blood Pressure Targets

• Target BP should be <130/80 mmHg for patients with diabetes and CKD 1
• This lower target is supported by evidence showing reduced cardiovascular events and slower progression of kidney disease 1

Monitoring Recommendations

1. Short-term monitoring (2-4 weeks after medication change):

   • Check serum creatinine and potassium
   • A rise in creatinine up to 30% is acceptable and not a reason to discontinue ACE inhibitor therapy 2
   • Monitor for hyperkalemia, especially with reduced GFR 2

2. Long-term monitoring:

   • Monthly evaluation of adherence and therapeutic response until BP control is achieved 1
   • Regular assessment of albuminuria (spot urine albumin-to-creatinine ratio) 2
   • Monitor eGFR trend every 3-6 months

Common Pitfalls to Avoid

1. Inappropriate discontinuation of ACE inhibitors:

   • Don't discontinue lisinopril if creatinine rises <30% from baseline 2
   • ACE inhibitors provide superior renoprotection compared to other antihypertensive classes in diabetic nephropathy 1, 4

2. Therapeutic inertia:

   • Don't delay adding additional agents if BP remains uncontrolled 1
   • African-American patients often require multiple agents for adequate BP control 1

3. Volume depletion:

   • Start loop diuretics at lower doses and titrate gradually to avoid acute kidney injury 2
   • Monitor for signs of volume depletion when using diuretics with ACE inhibitors 3

4. Drug interactions:

   • Avoid NSAIDs as they can worsen kidney function when combined with ACE inhibitors 3
   • Avoid dual RAS blockade (ACE inhibitor + ARB) as this increases risk of hyperkalemia without additional benefit 2

By implementing these evidence-based changes to the antihypertensive regimen, you can optimize blood pressure control while providing renoprotection for this high-risk patient with declining kidney function and diabetes.