From the Guidelines
In advanced CKD stage 4, ARBs are the preferred choice for hypertension management due to their renoprotective effects, as evidenced by the 2020 KDIGO clinical practice guideline 1. When considering the management of hypertension in advanced chronic kidney disease (CKD) stage 4, the primary goal is to slow the progression of kidney disease while minimizing cardiovascular risk.
- The use of ARBs (angiotensin receptor blockers) is supported by recent clinical guidelines, such as the 2020 KDIGO clinical practice guideline, which recommends the use of RAS inhibitors, including ARBs, in patients with diabetes, hypertension, and albuminuria to reduce the risk of CKD progression and cardiovascular events 1.
- ARBs, such as losartan or valsartan, are generally preferred over other antihypertensive agents for their ability to reduce proteinuria and slow CKD progression through their effects on the renin-angiotensin-aldosterone system.
- However, the use of ARBs in advanced CKD requires careful monitoring due to the potential risks of hyperkalemia and acute kidney injury, necessitating regular checks of serum creatinine and potassium levels within 2 to 4 weeks of initiation or dose changes, as recommended by the guideline 1.
- Aveo (tivozanib), on the other hand, is primarily used for the treatment of advanced renal cell carcinoma and is not indicated for the management of CKD itself.
- In the context of advanced CKD stage 4, the decision to use ARBs should be based on the patient's specific clinical context, including the presence of diabetes, hypertension, and albuminuria, and should always prioritize the minimization of morbidity, mortality, and improvement of quality of life.
- The FIDELIO trial, which reported that treatment with finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist, in patients with CKD and type 2 diabetes already on RAS blockade resulted in lower risks for CKD progression and cardiovascular events, further supports the use of RAS inhibitors, including ARBs, in the management of advanced CKD 1.
From the Research
Aveo or ARB in Advanced CKD 4
- The use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) in advanced chronic kidney disease (CKD) is a topic of ongoing research 2, 3, 4, 5, 6.
- A study published in 2016, the STOP-ACEi trial, aimed to investigate the effects of withdrawing ACEi/ARB treatment in patients with advanced CKD, with the primary outcome measure being eGFR at 3 years 2.
- Another study published in 2021 discussed the benefits and problems of using RAS blockers in patients with CKD, highlighting the need for more research on their use in advanced CKD 3.
- A 2011 study found that ARBs provide renal protection and may be a more practical therapeutic option than ACEi, with telmisartan showing superior reductions in proteinuria compared to losartan 4.
- A 2020 study found no difference in risk for progression to end-stage renal disease (ESRD) or mortality across different patterns of RAS inhibitor use in patients with advanced CKD 5.
- A 2008 study demonstrated the renoprotective effects of the ARB candesartan cilexetil in patients with stage 4-5 CKD, with significant reductions in proteinuria and improved renal survival analysis 6.
Key Findings
- The use of ACEi/ARBs in advanced CKD may have benefits, but more research is needed to confirm their efficacy and safety 2, 3, 5.
- ARBs may be a more practical therapeutic option than ACEi, with some ARBs showing superior reductions in proteinuria 4.
- The renoprotective effects of ARBs have been demonstrated in patients with stage 4-5 CKD, with significant reductions in proteinuria and improved renal survival analysis 6.