From the Guidelines
The most appropriate treatment for this patient is to discontinue hydrochlorothiazide and begin furosemide (option B). This 57-year-old man with hypertension and chronic kidney disease has an estimated glomerular filtration rate (eGFR) of 28 mL/min/1.73 m², which indicates stage 4 chronic kidney disease.
Key Considerations
- Thiazide diuretics like hydrochlorothiazide become less effective when the eGFR falls below 30 mL/min/1.73 m², as stated in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
- The patient has developed peripheral edema despite being on hydrochlorothiazide, suggesting it is not effectively managing his fluid status.
- His potassium level is elevated at 5.4 mEq/L, which is concerning given his kidney disease and ACE inhibitor use.
Rationale for Furosemide
- Loop diuretics like furosemide remain effective even in advanced kidney disease and would be more appropriate for managing fluid overload in this patient, as indicated in the guideline 1.
- Furosemide will help reduce edema while being more effective at his current level of kidney function.
Why Other Options are Inappropriate
- Continuing hydrochlorothiazide or increasing its dose would be inappropriate given his reduced kidney function.
- Eplerenone, a potassium-sparing diuretic, would further worsen his hyperkalemia, especially considering his chronic kidney disease and the use of an ACE inhibitor, lisinopril. According to the guideline, potassium-sparing diuretics like eplerenone should be used with caution in patients with significant CKD (eg, GFR <45 mL/min) 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient's Condition
The patient is a 57-year-old man with hypertension and chronic kidney disease, currently taking lisinopril, amlodipine, and hydrochlorothiazide. He has a blood pressure of 138/86 mm Hg, 1+ pitting pretibial edema bilaterally, and laboratory results showing hyperkalemia (potassium level of 5.4 mEq/L) and an estimated glomerular filtration rate of 28 mL/min/1.73 m2.
Treatment Options
Considering the patient's condition, the following treatment options are available:
- Discontinue hydrochlorothiazide and begin eplerenone
- Discontinue hydrochlorothiazide and begin furosemide
- Increase hydrochlorothiazide dose
- Continue current management
Rationale for Treatment
The patient's hyperkalemia is a concern, and the use of hydrochlorothiazide, a thiazide diuretic, may be contributing to this condition 2. The addition of eplerenone, an aldosterone antagonist, may help to reduce potassium levels and improve the patient's condition 3. On the other hand, furosemide, a loop diuretic, may also be effective in reducing potassium levels, but its use may be limited by the patient's chronic kidney disease 4, 5.
Recommended Treatment
Based on the available evidence, the most appropriate treatment option is to discontinue hydrochlorothiazide and begin eplerenone. This option takes into account the patient's hyperkalemia and the potential benefits of aldosterone antagonism in reducing potassium levels and improving cardiovascular outcomes 3.
Key Points to Consider
- The patient's hyperkalemia is a significant concern and requires prompt attention
- The use of hydrochlorothiazide may be contributing to the patient's hyperkalemia
- Eplerenone may be a suitable alternative to hydrochlorothiazide, given its potential benefits in reducing potassium levels and improving cardiovascular outcomes
- Furosemide may also be effective in reducing potassium levels, but its use requires careful consideration in patients with chronic kidney disease 4, 5