What is the recommended initial antihypertensive medication for a patient with stage 2 Chronic Kidney Disease (CKD) and Hypertension: Lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor) or Candesartan (Angiotensin II Receptor Blocker (ARB))?

Lisinopril is the Recommended First-Line Antihypertensive for CKD Stage 2 with Hypertension

For a 54-year-old female with stage 2 CKD and newly diagnosed hypertension, lisinopril (an ACE inhibitor) should be recommended as the initial antihypertensive medication rather than candesartan (an ARB). 1

Rationale for ACE Inhibitor Selection

Guidelines Support for ACE Inhibitors in CKD

• The 2017 ACC/AHA hypertension guideline recommends initiating antihypertensive therapy for this patient with stage 1 hypertension (136/88 mmHg) and a 10-year ASCVD risk of 5.7% 1
• KDOQI guidelines specifically recommend ACE inhibitors as first-line therapy for hypertensive patients with CKD stages 1-4: "Hypertensive people with diabetes and CKD stages 1-4 should be treated with an ACE inhibitor or an ARB, usually in combination with a diuretic" 1

Benefits of Renin-Angiotensin System Inhibition in CKD

• Both ACE inhibitors and ARBs provide renoprotection by:
  • Reducing intraglomerular pressure
  • Decreasing proteinuria
  • Slowing progression of kidney disease 1
• The 2024 KDIGO guidelines recommend starting RAS inhibitors (either ACE inhibitors or ARBs) for people with CKD 1

Why Lisinopril Over Candesartan in This Case

1. Equivalent Efficacy: Both ACE inhibitors and ARBs are considered to have similar benefits and risks for renoprotection in CKD 1

2. Dosing Considerations:

   • For this patient with stage 2 CKD (eGFR likely >60 ml/min/1.73m²), lisinopril can be started at standard doses (10 mg daily) 2
   • No dose adjustment is required for lisinopril in patients with creatinine clearance >30 mL/min 2

3. Monitoring Requirements:

   • After initiating therapy, serum creatinine and potassium should be checked within 2-4 weeks 1
   • Continue ACE inhibitor therapy unless serum creatinine rises by more than 30% within 4 weeks 1

Implementation and Monitoring

• Initial Dosing: Start lisinopril at 10 mg once daily 2
• Combination Therapy: Consider adding hydrochlorothiazide (12.5 mg) if blood pressure is not adequately controlled with lisinopril alone 2
• Target Blood Pressure: <130/80 mmHg for patients with CKD 1
• Follow-up: Reassess blood pressure in 1 month 1

Important Considerations and Precautions

• Hyperkalemia Risk: Monitor serum potassium, especially in CKD patients 1
• Initial GFR Decline: A small, reversible decrease in eGFR (up to 30%) after starting therapy is expected and not a reason to discontinue therapy 1
• Avoid Combination RAS Blockade: Never combine ACE inhibitors with ARBs due to increased risk of adverse events without additional benefits 1

While both lisinopril and candesartan would be appropriate choices based on guidelines, lisinopril is recommended as the initial agent based on the established efficacy of ACE inhibitors in CKD and the specific recommendations from multiple guidelines.