From the Guidelines
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are the first-line blood pressure medications recommended for patients with chronic kidney disease (CKD), as they not only lower blood pressure but also reduce proteinuria and slow CKD progression by decreasing intraglomerular pressure, as supported by the most recent guideline from KDIGO in 2024 1. The preferred ACEIs include lisinopril (10-40 mg daily), enalapril (5-40 mg daily in divided doses), and ramipril (2.5-20 mg daily), while frequently prescribed ARBs include losartan (25-100 mg daily), valsartan (80-320 mg daily), and irbesartan (150-300 mg daily) 1. Some key points to consider when using these medications in CKD patients include:
- Monitoring potassium levels, as ACEIs and ARBs can cause hyperkalemia, especially in advanced CKD 1
- Checking kidney function within 2-4 weeks of starting or adjusting these medications, with dose adjustments made if creatinine increases by more than 30% from baseline 1
- Considering combination therapy to achieve target blood pressure (<130/80 mmHg), with second-line agents including dihydropyridine calcium channel blockers like amlodipine (5-10 mg daily) or thiazide-like diuretics such as chlorthalidone (12.5-25 mg daily) 1
- Avoiding the combined use of ACE inhibitors and ARBs, as it has been shown to have no benefits on CVD or CKD and increases the risk of adverse events such as hyperkalemia and/or AKI 1
From the FDA Drug Label
2.3 Nephropathy in Type 2 Diabetic Patients The usual starting dose is 50 mg once daily. The dose should be increased to 100 mg once daily based on blood pressure response [see CLINICAL STUDIES (14.3)]. The recommended blood pressure medication for patients with CKD (specifically nephropathy in type 2 diabetic patients) is losartan, with a starting dose of 50 mg once daily, which can be increased to 100 mg once daily based on blood pressure response 2.
- The medication is specifically recommended for patients with nephropathy in type 2 diabetes.
- The dosage can be adjusted according to blood pressure response.
From the Research
Recommended Blood Pressure Medications for Patients with CKD
The following medications are recommended for patients with chronic kidney disease (CKD):
- ACE inhibitors: These are considered first-line therapy for patients with CKD 3, 4, 5, 6, 7
- Angiotensin receptor blockers (ARBs): These can be used as an alternative to ACE inhibitors, especially in patients who cannot tolerate ACE inhibitors 4, 5, 6, 7
- Combination therapy: Combination of ACE inhibitors and ARBs can be used in some cases, but it is not recommended for all patients with CKD due to the increased risk of adverse effects 3, 5, 7
Benefits of ACE Inhibitors and ARBs
The benefits of ACE inhibitors and ARBs in patients with CKD include:
- Reduced risk of kidney events, such as end-stage renal disease (ESRD) 4, 7
- Reduced risk of cardiovascular events, such as heart attacks and strokes 4, 7
- Slowed progression of renal insufficiency 6
- Cardio-protective effects, such as reduced risk of cardiovascular death and all-cause death 7
Adverse Effects of ACE Inhibitors and ARBs
The adverse effects of ACE inhibitors and ARBs include:
- Hyperkalemia (high potassium levels) 3, 5, 7
- Hypotension (low blood pressure) 3, 7
- Cough 7
- Renal function impairment 3
Monitoring and Dose Titration
Patients with CKD who are taking ACE inhibitors or ARBs should be monitored regularly for adverse effects, such as hyperkalemia and hypotension 3, 5. The dose of these medications should be titrated carefully to minimize the risk of adverse effects while maximizing the benefits 5.