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Treatment of hypertension in chronic renal insufficiency
F Locatelli1, C Manzoni, D Marcelli
1Department of Nephrology and Dialysis Hospital of Lecco, Italy.
Insights
Correcting hypertension and proteinuria slows chronic renal insufficiency (CRI) progression. Combining ACE inhibitors or angiotensin II receptor antagonists with calcium-channel blockers may be necessary to reach blood pressure targets in CRI patients.
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Pharmacology
Background:
- Hypertension and proteinuria accelerate chronic renal insufficiency (CRI) progression.
- Renal hemodynamic impairment, influenced by the renin-angiotensin system, links hypertension and CRI.
- ACE inhibitors and non-dihydropyridine calcium-channel blockers offer antiproteinuric and renoprotective effects.
Purpose of the Study:
- To evaluate the renoprotective effects of different antihypertensive drug classes in patients with chronic renal insufficiency.
- To determine if ACE inhibitors or angiotensin II receptor antagonists are superior to calcium-channel blockers in slowing CRI progression.
- To establish the pharmacological rationale for combining antihypertensive drug classes in CRI management.
Main Methods:
- Review of existing clinical trials demonstrating the importance of blood pressure and proteinuria management in CRI.
- Analysis of the pharmacological mechanisms of ACE inhibitors, angiotensin II receptor antagonists, and calcium-channel blockers on renal hemodynamics.
- Identification of the need for prospective, controlled, randomized long-term trials to compare renoprotective efficacy.
Main Results:
- ACE inhibitors and certain calcium-channel blockers demonstrate antiproteinuric and renoprotective actions.
- Angiotensin II receptor antagonists are hypothesized to have similar renoprotective effects.
- A clear need exists for trials comparing the superior renoprotective effects of ACE inhibitors/ARBs versus CCBs.
Conclusions:
- Managing hypertension and proteinuria is crucial for slowing CRI progression.
- Combination therapy with ACE inhibitors (or ARBs) and CCBs may be required to achieve target blood pressure (120/80 mmHg) in proteinuric CRI patients.
- Further long-term randomized trials are essential to confirm superior renoprotective strategies.
Abstract:
Several trials clearly demonstrate the importance of correcting hypertension and proteinuria in slowing chronic renal insufficiency (CRI) progression. The relationship between hypertension and CRI is at least partly the consequence of impaired renal hemodynamics, mainly mediated by the renin-angiotensin system. Two classes of drugs have so far been shown to have an antiproteinuric and renoprotective effect, in addition to their antihypertensive action: ACE inhibitors and calcium-channel blockers (at least the non-dihydropyridines) which also interfere with the actions of angiotensin II. The same should be true for the newest angiotensin II receptor antagonists. To find conclusive evidence about the superior renoprotective effect of ACE inhibitors (or angiotensin II receptor antagonists) or calcium-channel blockers, we need well-designed, prospective, controlled and randomized long-term trials; the pharmacological rationale for combining the two classes of antihypertensive drugs is supported by the clinical need to reach a target blood pressure (120/80 mmHg) in CRI patients with proteinuria.