michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
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TREATMENT OF HYPERTENSION IN PATIENTS WITH CHRONIC KIDNEY DISEASE (CKD)<br />
Pretest Questions:<br />
Mark D Faber, MD<br />
1. Which ONE <strong>of</strong> the following statements about the use <strong>of</strong> ACE inhibitors (ACEI) or ARBs in patients<br />
with stage 3 CKD (GFR 30-59 ml/min/1.73 m 2 ) is MOST correct?<br />
a. A 20% increase in serum creatinine indicates the likely presence <strong>of</strong> bilateral renal artery<br />
stenosis and is a contraindication to continued use <strong>of</strong> the drug until after renal artery<br />
revascularization.<br />
b. The use <strong>of</strong> an ACEI or ARB in patients with proteinuric stage 3 CKD can be expected on<br />
average to decrease proteinuria by 35%. (correct answer)<br />
c. There is evidence from multiple controlled trials that the use <strong>of</strong> an ACEI with an ARB in patients<br />
with proteinuric stage 3 CKD reduces the rate <strong>of</strong> GFR loss more than the use <strong>of</strong> either drug<br />
alone.<br />
d. The antiproteinuric effects <strong>of</strong> ACEI or ARB therapy are reduced by the concurrent use <strong>of</strong> a<br />
diuretic<br />
2. Which ONE <strong>of</strong> the following statements concerning the treatment <strong>of</strong> <strong>hypertension</strong> in patients with<br />
diabetes mellitus is MOST correct?<br />
a. In the absence <strong>of</strong> specific contraindications, antihypertensive medication is indicated in all<br />
diabetic patients once the blood pressure reaches ≥ 140/90.<br />
b. Type 2 diabetic patients without nephropathy treated with captopril demonstrated fewer<br />
microvascular and macrovascular complications than patients treated with atenolol, despite<br />
equivalent levels <strong>of</strong> blood pressure. (correct answer)<br />
c. The recommended blood pressure goal for adult patients with diabetes mellitus is 135/85.<br />
d. The reductions in proteinuria and risk <strong>of</strong> end stage renal disease associated with the use <strong>of</strong><br />
ACEI in diabetic patients with decreased GFR can be completely explained by concomitant<br />
reductions in blood pressure.<br />
Overview<br />
Hypertension is present in over 80% <strong>of</strong> patients with CKD. Multiple factors contribute to this high<br />
prevalence, including: ECF volume expansion; activation <strong>of</strong> the <strong>of</strong> renin-angiotensin-aldosterone system<br />
(RAAS); sympathetic nervous system overactivity; impaired nitric oxide synthesis and release; and<br />
decreased vascular compliance related to mineral bone disease. The treatment <strong>of</strong> <strong>hypertension</strong> in<br />
patients with chronic kidney disease reflects the general principles <strong>of</strong> <strong>hypertension</strong> management (i.e.,<br />
inclusion <strong>of</strong> non-pharmacologic approaches and selecting drug regimens that are as safe, well-tolerated,<br />
convenient, and cost-effective as possible). However, the presence <strong>of</strong> low GFR or other manifestations<br />
<strong>of</strong> kidney disease introduces several additional concerns and considerations:<br />
1. There is a need to select target blood pressures (widely agreed to be ≤ 130/80) and therapies<br />
most likely to preserve residual renal function. In addition to glomerular <strong>hypertension</strong> and<br />
hypertrophy, proteinuria itself is considered to be a mediator <strong>of</strong> progressive renal damage (as<br />
well as being an adverse prognostic factor). Thus, reduction <strong>of</strong> proteinuria is acknowledged as<br />
another important, if only a partial surrogate, target <strong>of</strong> antihypertensive therapy. RAAS inhibitors<br />
NKFM & MDCH 247