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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y sodium restriction or the use <strong>of</strong> diuretics. Stricter BP control is also associated with reduction in<br />
proteinuria, which independently correlates with improved renal outcomes and mortality rates 5 . Multiple<br />
studies have now shown additional decreases in proteinuria <strong>of</strong> similar magnitude in patients with diabetic<br />
nephropathy when a second RAAS inhibitor is added to an ACEI or ARB. Combinations <strong>of</strong> an ACEI and<br />
ARB 6 or addition <strong>of</strong> spironolactone 7-10 or epleronone 11 in patients already taking an ACEI or ARB, were<br />
studied. Safety concerns in patients with decreased GFR include an initial decrease in GFR <strong>of</strong> 5-10 ml/<br />
min that correlates with the magnitude <strong>of</strong> proteinuria reduction and plateaus early during treatment. Of<br />
particular concern is an increase in the need for acute dialysis and a trend towards higher mortality that<br />
did not reach statistical significance in patients treated with an ACEI and ARB in the ONTARGET trial 12 .<br />
Many but not all studies <strong>of</strong> dual or triple RAAS inhibition report an increased risk <strong>of</strong> hyperkalemia as well.<br />
NDHP CCBs result in similar decreases in albuminuria, while most other antihypertensive drugs have<br />
little to no effect on proteinuria.<br />
The estimated lifetime risk <strong>of</strong> ESRD in patients with diabetes mellitus was approximately 16% prior<br />
to the widespread adoption <strong>of</strong> strict glycemic and BP control 13 . Doubling <strong>of</strong> serum creatinine occurred<br />
almost 78% <strong>of</strong> type I diabetics with overt proteinuria and a baseline serum creatinine ≥ 1.5 mg/dl who<br />
were randomized to receive antihypertensive medications other than ACE inhibitors or calcium channel<br />
blockers over a 4 year period. By comparison, in the group randomized to captopril, doubling <strong>of</strong> creatinine<br />
was observed in less than 36% <strong>of</strong> patients 14 . This benefit persisted after adjustment for the slightly lower<br />
BP maintained in the captopril group, and was not observed in patients with a baseline creatinine < 1.5<br />
mg/dL (whose rate <strong>of</strong> creatinine was < 10% regardless <strong>of</strong> treatment). Target blood pressures in this 1993<br />
study (< 140/90, or < 160 systolic and at least 10 mm Hg < baseline SBP) were higher than currently<br />
recommended targets, but probably reflective <strong>of</strong> blood pressures still commonly observed in clinical<br />
practice.<br />
Non-Diabetic Chronic Kidney Disease<br />
The management <strong>of</strong> <strong>hypertension</strong> in patients with non-diabetic CKD closely parallels that <strong>of</strong> CKD<br />
in patients with diabetes, as outlined above. Strict control <strong>of</strong> BP (≤ 130/80) reduces progression <strong>of</strong> CKD<br />
(loss <strong>of</strong> GFR) in a broad variety <strong>of</strong> non-diabetic kidney diseases as well as in diabetic nephropathy and<br />
is recommended by JNC-7 1 for patients with CKD. In contrast, the specific benefits <strong>of</strong> RAAS inhibition<br />
are limited to proteinuric (i.e., glomerular) diseases. This is largely expected in that 1) diabetes itself,<br />
250 Hypertension Core Curriculum