Use of ACE inhibition and blood pressure management in deferring dialysis initiation

Panminerva Med. 2017 Jun;59(2):166-172. doi: 10.23736/S0031-0808.17.03293-1. Epub 2017 Jan 13.

Abstract

Elevated blood pressure is one of the most significant risk factor for the development of chronic kidney disease (CKD); its treatment is a milestone in CKD management. While it is accepted that a stricter blood pressure control is indicated in patients with proteinuria or microalbuminuria, the exact degree of blood pressure reduction to be obtained in CKD patients is still under debate. Following more recent interpretation of old trials, a BP target for <140/90 mmHg is suggested for non-proteinuric CKD patients. In those with microalbuminuria/proteinuria, the ideal blood pressure target should be ≤130/80 mmHg. Recently, the SPRINT trial put new emphasis on a stricter blood pressure control, mainly from the cardiovascular point of view. The blockers of the renin-angiotensin system (RAS) are recommended as first line treatment in all CKD hypertensive patients with micro or macroalbuminuria either diabetics or not. However, their nephroprotective efficacy is less relevant in non-proteinuric patients. The dual RAS blockade was proposed as an additional option. Despite a greater antiproteinuric effect, some large trials in patients at high cardiovascular risk did not demonstrate significant advantage on hard endpoint. Its use is now contraindicated in diabetic CKD patients. Given that RAS blockers can cause acute derangements in kidney function and hyperkalemia, caution is needed with their use, especially in frail and old patients with cardiovascular disease or in the presence of advanced CKD.

Publication types

  • Review

MeSH terms

  • Albuminuria / therapy
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Antihypertensive Agents / therapeutic use
  • Blood Pressure / drug effects*
  • Cardiovascular Diseases / therapy
  • Drug Therapy, Combination
  • Humans
  • Hypertension / complications
  • Hypertension / physiopathology
  • Hypertension / therapy
  • Kidney / pathology
  • Kidney Failure, Chronic / complications
  • Kidney Failure, Chronic / therapy
  • Proteinuria
  • Renal Dialysis / methods*
  • Renin-Angiotensin System
  • Risk Factors
  • Time-to-Treatment

Substances

  • Angiotensin-Converting Enzyme Inhibitors
  • Antihypertensive Agents