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

Area of Science:

• Nephrology
• Cardiology
• Pharmacology

Background:

• Elevated blood pressure is a primary risk factor for chronic kidney disease (CKD) development and progression.
• Effective blood pressure management is essential for CKD patient care.
• Optimal blood pressure targets in CKD patients, particularly those with proteinuria, remain a subject of ongoing discussion.

Purpose of the Study:

• To review current recommendations for blood pressure targets in patients with chronic kidney disease.
• To discuss the role of renin-angiotensin system (RAS) blockers in managing hypertension in CKD.
• To highlight considerations for RAS blockade, including dual blockade, and associated risks.

Main Methods:

• Review of recent clinical trial interpretations, including the SPRINT trial.
• Analysis of guidelines regarding blood pressure targets based on proteinuria levels.
• Evaluation of the efficacy and safety of RAS blockers and dual RAS blockade in CKD.

Main Results:

• Suggested blood pressure targets: <140/90 mmHg for non-proteinuric CKD and ≤130/80 mmHg for CKD with microalbuminuria/proteinuria.
• RAS blockers are first-line for CKD hypertensive patients with albuminuria, but less effective in non-proteinuric CKD.
• Dual RAS blockade shows antiproteinuric effects but lacks proven benefits on hard endpoints and is contraindicated in diabetic CKD.

Conclusions:

• Stricter blood pressure control is emphasized, especially post-SPRINT trial.
• RAS blockers require cautious use in CKD due to potential kidney function derangements and hyperkalemia, particularly in vulnerable populations.
• Individualized treatment strategies are necessary, considering proteinuria, comorbidities, and patient frailty.