What is the best anti-hypertensive (antihypertensive) medication for patients with impaired renal function (kidney failure)?

From the Guidelines

For patients with kidney failure and hypertension, ACE inhibitors or Angiotensin II Receptor Blockers (ARBs) are generally considered first-line treatments, as they not only lower blood pressure but also provide kidney protection. These medications work by blocking the renin-angiotensin-aldosterone system, which helps reduce both systemic blood pressure and the pressure within the kidneys' filtering units 1. Typical starting doses are lower in kidney failure - for example, lisinopril 2.5-5mg daily or losartan 25-50mg daily, with careful dose adjustments based on blood pressure response and kidney function monitoring.

Some key points to consider when using these medications include:

• Monitoring potassium levels and kidney function regularly, as they can cause potassium retention, especially in advanced kidney failure 1
• Combination therapy may be needed, often adding a calcium channel blocker (like amlodipine) or a diuretic appropriate for the patient's level of kidney function 1
• Blood pressure targets should generally aim for readings below 130/80 mmHg in most kidney failure patients, though individualization based on age, comorbidities, and tolerance is essential 1
• The use of ACE inhibitors or ARBs may provide cardiovascular benefit without significantly increasing the risk of end-stage kidney disease, even as kidney function declines to estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 1

In terms of specific patient populations, it's worth noting that:

• For individuals with albuminuria (urine albumin-to-creatinine ratio [UACR] $30 mg/g), initial treatment should include an ACE inhibitor or ARB to reduce the risk of progressive kidney disease 1
• In the absence of albuminuria, the risk of progressive kidney disease is low, and ACE inhibitors and ARBs have not been found to afford superior cardioprotection compared with thiazide-like diuretics or dihydropyridine calcium channel blockers 1

From the FDA Drug Label

1. 3 Impaired Renal Function Monitor renal function periodically in patients treated with lisinopril. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, post-myocardial infarction or volume depletion) may be at particular risk of developing acute renal failure on lisinopril. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril [see Adverse Reactions (6. 1), Drug Interactions (7.4)].

The best anti-hypertensive for kidney failure is not explicitly stated in the provided drug labels. However, lisinopril and losartan are both mentioned in the context of renal function and kidney disease.

• Lisinopril may be used in patients with kidney disease, but it is recommended to monitor renal function periodically and consider withholding or discontinuing therapy if a clinically significant decrease in renal function occurs 2.
• Losartan may also be used in patients with kidney disease, and it is recommended to monitor renal function periodically in patients receiving losartan and NSAID therapy 3. It is essential to consult a healthcare professional to determine the best course of treatment for a patient with kidney failure, as the decision depends on various factors, including the patient's specific condition, medical history, and other medications they are taking.

From the Research

Anti-Hypertensive Medications for Kidney Failure

The choice of anti-hypertensive medication for patients with kidney failure is crucial, as it can significantly impact their renal function and overall health.

• ACE inhibitors are often recommended as a first-line treatment for patients with chronic kidney disease (CKD) due to their ability to reduce systemic blood pressure, intraglomerular pressure, and proteinuria 4, 5.
• However, ACE inhibitors can also have adverse effects, such as hypotension, renal function impairment, and hyperkalemia, particularly in patients with pre-existing renal insufficiency 5, 6.
• The pharmacokinetics of ACE inhibitors can be altered in patients with renal failure, leading to increased accumulation of the drug and its active metabolites 6.
• Angiotensin antagonists are an alternative to ACE inhibitors and may have a more favorable adverse effect profile, particularly in patients with end-stage renal disease (ESRD) 7.
• The risk of acute renal failure associated with ACE inhibitors can be minimized by avoiding dehydration and monitoring renal function closely, especially in older patients with congestive heart failure 8.

Considerations for Specific Patient Populations

• Elderly patients with diabetes, coronary heart disease, or peripheral vascular occlusion are at risk for deterioration of kidney function due to a high frequency of renal artery stenosis 4.
• Patients with renal insufficiency require dose reduction of ACE inhibitors, except for fosinopril, and should be monitored for hyperkalemia 4, 6.
• Patients with ESRD may benefit from angiotensin antagonists due to their non-dialyzable nature and reduced risk of anaphylactoid dialyser reactions 7.