michigan hypertension core curriculum - State of Michigan

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