Can I give amlodipine (calcium channel blocker) 5 mg to a patient with Chronic Kidney Disease (CKD) stage 3b, blood pressure 154/80 mmHg, and serum creatinine (kidney function test) of 1.9 mg/dL to control blood pressure, and also use furosemide (loop diuretic) to decrease serum creatinine?

Amlodipine and Furosemide in CKD Stage 3b Hypertension Management

Yes, amlodipine 5 mg is appropriate for this CKD 3b patient with BP 154/80 mmHg, and furosemide can be added if needed for volume control, but an ACE inhibitor or ARB should be the first-line agent if albuminuria is present.

Blood Pressure Target in CKD

• Current guidelines recommend a BP target of <130/80 mmHg for patients with CKD 1
• This recommendation is based on evidence from the SPRINT trial, which included patients with CKD stage 3 and showed cardiovascular benefits with intensive BP control 1
• With a current BP of 154/80 mmHg, this patient requires antihypertensive therapy to reduce cardiovascular risk and slow CKD progression

Medication Selection Algorithm for CKD 3b

1. First-line therapy:

   • ACE inhibitor or ARB is the preferred first-line agent in CKD patients, especially if albuminuria is present (≥300 mg/day) 1
   • These agents slow kidney disease progression by reducing intraglomerular pressure 1

2. Second-line therapy (or first-line if ACEi/ARB contraindicated):

   • Calcium channel blockers like amlodipine are appropriate options 1, 2
   • Amlodipine 5 mg is safe in CKD 3b as it requires no dose adjustment in renal impairment 3
   • Amlodipine effectively reduces BP in CKD patients and has demonstrated cardiovascular benefits 4

3. Additional therapy for volume control:

   • Loop diuretics like furosemide are appropriate in moderate-to-severe CKD with signs of volume overload 1, 2
   • They help manage volume status but do not directly reduce serum creatinine

Important Considerations

• Amlodipine safety: Pharmacokinetics of amlodipine are not significantly altered in renal impairment, making it safe for use in CKD 3b 3
• Monitoring: After starting amlodipine, monitor BP response and adjust dose as needed to achieve target BP <130/80 mmHg 1
• Furosemide clarification: Furosemide will not directly decrease serum creatinine but may help control BP by managing volume status 2
• Combination therapy: Most CKD patients require multiple agents to achieve BP targets 1

Potential Pitfalls

• Misconception about furosemide: Furosemide does not directly improve GFR or reduce serum creatinine; it manages volume status and helps control BP 2
• ACEi/ARB caution: When starting ACEi/ARB, monitor for acute rise in creatinine (up to 30% increase may be acceptable) and hyperkalemia 1
• CCB limitations: While effective for BP control, some studies suggest CCBs like amlodipine may be less effective than ACEi/ARB in slowing CKD progression in proteinuric patients 5
• Avoid dual RAAS blockade: Combination of ACEi and ARB increases risk of hyperkalemia and acute kidney injury without additional benefit 1

Monitoring Recommendations

• Check serum creatinine and potassium 2-4 weeks after initiating or adjusting doses of antihypertensive medications 2
• Monitor BP regularly to ensure target <130/80 mmHg is achieved 1
• Assess for signs of volume overload or depletion, especially when using diuretics

In conclusion, amlodipine 5 mg is an appropriate choice for this CKD 3b patient with elevated BP, and furosemide can be added for volume management if needed, but consider an ACEi/ARB as first-line therapy if albuminuria is present and not contraindicated.