What is the initial management for a patient with polycystic kidney disease (PKD), chronic kidney disease (CKD) stage 5, hypertension, and anasarca?

Initial Management of PKD with CKD Stage 5, Hypertension, and Anasarca

For this patient with polycystic kidney disease, CKD stage 5, hypertension, and anasarca, initiate aggressive volume management with loop diuretics (furosemide) to address fluid overload, combined with an ACE inhibitor or ARB for blood pressure control, while preparing for renal replacement therapy.

Volume Management (Priority #1)

The presence of anasarca in CKD stage 5 indicates severe volume overload requiring immediate attention:

• Start loop diuretics (furosemide) at appropriate doses for advanced CKD 1. Thiazide diuretics are ineffective at this level of kidney function and should be avoided 2.
• Initial furosemide dosing typically requires 40-80 mg, with doses potentially titrated up to 600 mg/day in severe edematous states, given in divided doses 1.
• Volume control is essential before optimizing blood pressure medications, as excessive fluid retention is a primary driver of hypertension in advanced CKD 2.
• Achievement of "dry weight" should be pursued, though this may require dialysis initiation if medical management fails 2.

Blood Pressure Management

Target Blood Pressure

For CKD stage 5, blood pressure targets are less aggressive than earlier CKD stages:

• Target blood pressure <140/90 mm Hg for patients with advanced CKD (stages 4-5) 2.
• The more intensive targets (<120 mm Hg systolic) recommended for CKD stages 1-3 are not supported by evidence in stage 5 CKD 2.
• Avoid excessive blood pressure lowering, as diastolic blood pressure should not fall below 80 mm Hg, particularly in older patients with arterial stiffness 2.

Antihypertensive Medication Selection

First-line therapy: ACE inhibitor or ARB 2:

• For ADPKD specifically, renin-angiotensin system inhibitors are recommended as first-line agents 2.
• Avoid combination therapy with ACE inhibitor + ARB, as this provides no additional benefit and increases risk of hyperkalemia and acute kidney injury in advanced CKD 2, 3.
• Starting dose for lisinopril in CKD stage 5: 2.5 mg once daily (for creatinine clearance <10 mL/min or hemodialysis patients), titrated as tolerated to maximum 40 mg daily 4.

Second-line agents (if blood pressure remains uncontrolled):

• Calcium channel blockers can be added, though they may increase proteinuria compared to RAAS inhibitors 5.
• Beta-blockers are appropriate if coronary artery disease is present 2.
• Multiple medications (typically 3 or more) are usually required in advanced CKD 2.

Important Caveats for Advanced CKD

• Monitor for hyperkalemia closely when using ACE inhibitors or ARBs in stage 5 CKD 2, 3.
• Monitor for acute kidney injury, as intensive blood pressure lowering may accelerate need for dialysis in some patients with advanced CKD 2.
• If blood pressure remains uncontrolled despite 3 antihypertensive agents at optimal doses plus achievement of dry weight, evaluate for secondary causes of resistant hypertension 2.

Preparation for Renal Replacement Therapy

Given CKD stage 5 status:

• Initiate dialysis planning immediately if not already done, as anasarca suggests inadequate kidney function to maintain fluid balance 2.
• Consider vascular access placement for hemodialysis or peritoneal dialysis catheter insertion 2.
• In cases of truly resistant hypertension despite dialysis and multiple medications, bilateral nephrectomy may be considered as a last resort 2.

Monitoring Parameters

• Serum potassium and creatinine within 1-2 weeks of starting or adjusting ACE inhibitor/ARB 2.
• Daily weights to assess volume status 2.
• Blood pressure monitoring (home or ambulatory monitoring preferred over office readings alone) 2.
• Assess for orthostatic hypotension, particularly in elderly patients 2.