From the Guidelines
For a patient with Autosomal Dominant Polycystic Kidney Disease (ADPKD) who has hypertension and impaired renal function, I strongly recommend using an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) as the first-line antihypertensive treatment. This recommendation is based on the largest evidence base for efficacy and safety in patients with renal hypertension, as noted in the international consensus statement on the diagnosis and management of ADPKD 1. The use of ACE inhibitors or ARBs has been shown to be superior to other antihypertensive agents in patients with proteinuria, which is often present in ADPKD.
Key Considerations
- ACE inhibitors or ARBs should be initiated at lower doses due to impaired renal function, with careful monitoring of blood pressure, potassium, and creatinine levels.
- Blood pressure target should be <130/80 mmHg, with regular monitoring and adjustments as needed.
- Dual RAAS blockade is not recommended, as it does not seem to have additional benefit on disease progression over improved blood pressure control compared to an ACE inhibitor or ARB alone 1.
- Diuretics, such as loop diuretics, may be added to manage volume overload, but should be used with caution due to potential deleterious effects on estimated GFR (eGFR) in ADPKD 1.
Medication Selection
- Examples of ACE inhibitors include lisinopril, which can be started at a dose of 2.5-5 mg daily, and losartan, an ARB, which can be started at a dose of 25-50 mg daily.
- These medications should be adjusted based on blood pressure response and tolerance, with careful monitoring of laboratory values.
Additional Recommendations
- Regular monitoring of potassium, creatinine, and blood pressure is essential, with laboratory checks within 1-2 weeks of initiation.
- Nephrology referral may be necessary for patients with severely impaired renal function, as they may be approaching end-stage renal disease.
From the FDA Drug Label
The provided drug labels do not directly address the recommended antihypertensive regimen for a patient with Autosomal Dominant Polycystic Kidney Disease (ADPKD) who has hypertension and impaired renal function.
The FDA drug label does not answer the question.
From the Research
Antihypertensive Regimen for ADPKD Patients
The recommended antihypertensive regimen for a patient with Autosomal Dominant Polycystic Kidney Disease (ADPKD) who has hypertension and impaired renal function includes:
- Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) as the first-line treatment, as they have beneficial effects on proteinuria and declining renal function 2, 3
- The addition of diuretics and calcium channel antagonists to RAS inhibitor therapy is also considered a rational strategy to reduce blood pressure and preserve renal function 2, 3
- Non-dihydropyridine calcium channel blockers (CCBs) can consistently reduce albuminuria and slow the decline in kidney function, while dihydropypidine CCBs should not be used as monotherapy in proteinuric CKD patients but always in combination with a RAAS blocker 3
Combination Therapy
Combination antihypertensive drugs, including ACE inhibitors and ARBs, can reduce proteinuria and blood pressure in patients with renal disease, and may be used to achieve a target blood pressure of less than 130/80 mmHg 4, 5
- The combination of an ACE inhibitor and an ARB can reduce plasma and kidney tissue angiotensin II levels beyond what is observed with either of these two agents alone 5
Blood Pressure Goals
The target blood pressure for patients with ADPKD and impaired renal function is less than 130/80 mmHg, which may require lifestyle modifications and multiple antihypertensive medications 3
- International guidelines recommend lowering blood pressure to 140/90 mmHg or less in patients with uncomplicated hypertension, and to 130/80 mmHg or less for patients with diabetic or chronic renal disease 2