From the Guidelines
For patients with CKD stage 3, the blood pressure target should be less than 130/80 mm Hg, as supported by the SPRINT study results 1. This recommendation is based on the evidence that intensive blood pressure management in patients with CKD stage 3 to 4 provides benefits for reduction in the cardiovascular composite primary outcome and all-cause mortality, as seen in the SPRINT study 1. The American College of Cardiology/American Heart Association guideline for the prevention, detection, evaluation, and management of high blood pressure in adults also supports this target, citing the importance of treating hypertension to prevent further kidney functional decline and reduce the risk of adverse cardiovascular and cerebrovascular events 1. Key considerations in managing hypertension in patients with CKD include:
- Using an ACE inhibitor or an ARB as the preferred drug for treatment of hypertension if albuminuria is present, although the evidence is mixed 1
- Avoiding the combination of an ACE inhibitor and an ARB due to reported harms demonstrated in several large cardiology trials 1
- Monitoring for potential complications of intensive blood pressure treatment, such as hyperkalemia and hypotension, particularly in patients with additional comorbidities and evidence of frailty 1. In terms of overall management, patients with CKD should have their blood pressure carefully controlled, and evaluation and treatment of other complications of decreased GFR, such as anemia, malnutrition, bone disease, neuropathy, and decreased quality of life, should be undertaken as the prevalence of these complications begins to rise when GFR declines to less than 60 mL/min per 1.73 m2 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Chronic Kidney Disease Treatment
- The treatment of chronic kidney disease (CKD) can slow its progression to end-stage renal disease (ESRD) 2.
- Blood pressure control using angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) has the greatest weight of evidence for CKD treatment 2.
- Glycemic control in diabetes seems likely to retard CKD progression 2.
Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers
- ACE inhibitors and ARBs are two classes of antihypertensive drugs that act on the renin-angiotensin-aldosterone system 3.
- The effectiveness of ACEi and ARB in people with early CKD (stage 1 to 3) is less certain 3.
- There is currently insufficient evidence to determine the effectiveness of ACEi or ARB in patients with stage 1 to 3 CKD who do not have diabetes mellitus (DM) 3.
Prescription Rates of Angiotensin II Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors
- Despite guideline recommendations, ARBs and ACEIs are insufficiently prescribed for patients with hypertension associated with CKD with proteinuria 4.
- The prescription rate of ARBs/ACEIs was lower in patients aged <75 years with CKD stage G1-G5 compared with patients aged ≥75 years old with CKD stage G1-G3 4.
Combination Therapy with ACE Inhibitors and Angiotensin II Receptor Blockers
- Combination therapy with ACE inhibitors and angiotensin II receptor blockers may halt the progression of chronic renal disease 5.
- The rationale for combination therapy is based on several considerations, including the reduction of proteinuria and the slowing of renal disease progression 5.
Guidelines for Using Angiotensin-Converting Enzyme Inhibitors and Angiotensin II-Receptor Antagonists
- Current guidelines for the use of ACE inhibitors and angiotensin II-receptor antagonists in CKD are based on evidence with limited relevance to most persons older than 70 years with this condition 6.
- The evidence base for these guidelines may not be relevant to older adults, who account for a large and growing number of patients with CKD 6.