What peptides are beneficial for impaired renal function?

From the Guidelines

The use of angiotensin-converting enzyme (ACE) inhibitors, such as captopril, enalapril, and lisinopril, is beneficial for patients with impaired renal function to reduce morbidity and mortality, as they help protect kidney function by reducing blood pressure and decreasing protein in urine 1.

Mechanism of Action

These medications work by inhibiting the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, thereby reducing blood pressure and decreasing the amount of protein in the urine.

• ACE inhibitors have been shown to reduce morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF) 1.
• They should be started at low doses and titrated upward to doses shown to reduce the risk of cardiovascular events in clinical trials.
• ACE inhibitors can produce angioedema and should be given with caution to patients with low systemic blood pressures, renal insufficiency, or elevated serum potassium (>5.0 mEq/L) 1.

Alternative Options

For patients who are intolerant to ACE inhibitors, angiotensin receptor blockers (ARBs) may be used as an alternative, as they have been shown to reduce mortality and HF hospitalizations in patients with HFrEF 1.

• ARBs do not inhibit kininase and are associated with a much lower incidence of cough and angioedema than ACE inhibitors.
• They should be started at low doses and titrated upward, with an attempt to use doses shown to reduce the risk of cardiovascular events in clinical trials.
• ARBs should be given with caution to patients with low systemic blood pressure, renal insufficiency, or elevated serum potassium (>5.0 mEq/L) 1.

Additional Considerations

Natriuretic peptides, particularly B-type natriuretic peptide (BNP), can also benefit kidney function by promoting sodium excretion and vasodilation, though these are primarily used diagnostically rather than therapeutically.

• Ghrelin and its analogs show promise in experimental settings for reducing inflammation and oxidative stress in kidney tissue.
• For those with kidney disease, these medications should only be used under medical supervision as dosing may need adjustment based on kidney function, and regular monitoring of kidney function, blood pressure, and electrolyte levels is essential 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Peptides Beneficial for Impaired Renal Function

• Angiotensin-converting enzyme (ACE) inhibitors have been shown to be beneficial for patients with impaired renal function, as they can help slow the progression of renal function impairment 2, 3, 4, 5.
• ACE inhibitors can be subdivided into three classes: carboxyl-containing drugs, phosphoryl-group containing drugs, and sulfhydryl-containing drugs, such as captopril and lisinopril 2.
• The use of ACE inhibitors in patients with renal insufficiency necessitates careful consideration of dosages, titration, and monitoring, as renal function must be estimated to appropriately make dosage adjustments 4.
• Angiotensin receptor blockers (ARB) have also been shown to have beneficial effects on proteinuria and declining renal function, and are recommended as a first-line antihypertensive approach in patients with chronic kidney disease 3.
• Calcium channel antagonists, such as manidipine, may also have renal protective effects and can be used in combination with ACE inhibitors or ARB to reduce blood pressure and preserve renal function 3.

Specific Peptides and Their Effects

• Lisinopril, a nonsulfhydryl ACE inhibitor, has been shown to be effective in the treatment of hypertension and congestive heart failure, but may require dosage adjustments in patients with impaired renal function 2, 6.
• Captopril, a sulfhydryl-containing ACE inhibitor, has been shown to have beneficial effects on renal function, but may cause a decline in glomerular filtration rate (GFR) in patients with bilateral renal artery stenosis or stenosis of a solitary kidney 5.
• Enalapril, a carboxyl-containing ACE inhibitor, has been shown to cause higher incidences of renal function deterioration than captopril in patients with congestive heart failure 5.

Dosage Considerations

• Dosage recommendations for ACE inhibitors in patients with chronic renal failure depend on the specific pharmacokinetic properties of the various agents, and may require reductions in dosage and/or less frequent administration 2, 4.
• The use of diuretics, such as thiazide diuretics and loop diuretics, may also be necessary in patients with renal insufficiency, but requires careful consideration of dosages and monitoring to prevent hypovolemia, hyponatremia, and hypokalemia 4.