Considerations for initial therapy in patients with renal disease
Patients with renal disease frequently have increased blood volume and increased peripheral vascular resistance. Excess blood volume is more common in glomerular diseases.
Table Considerations for Initial Therapy in Patients with Renal Disease
| Pathophysiology | Desirable pharmacologic approach” |
| Increased blood volume (common in glomerular diseases) | Reduce blood volume (loop diuretic, avoid hydrochlorothiazide if creatinine >2.0). |
| Decreased blood volume (common in tubular diseases) | Possibly use salt supplementation. |
| Increased peripheral vascular resistance | Use a vasodilator (angiotensin-converting enzyme inhibitor, calcium channel blocker, ARB, a-blocker, minoxidil). |
| Proteinuria | Reduce proteinuria (angiotensin-converting enzyme inhibitor, ARB, NDCCB) (blood pressure systolic sl25 mmHg). |
| Diabetes with proteinuria | Control blood pressure and glycemia (angiotensin-converting enzyme inhibitor, NDCCB?, ARB?) (blood pressure
systolic sl25 mmHg). |
Patients with primary renal tubular disorders may present with a salt-losing nephropathy and diminished blood volume. If there is an abnormality in blood volume, it should be corrected. Volume overload will more likely be responsive to a loop diuretic, particularly if the serum creatinine is >2.0 mg/dL. Vasodilator therapy is ideal in conjunction with diuretic therapy. angiotensin-converting enzyme inhibitors, calcium channel blockers, angiotensin type 1 receptor blockers, a-blockers, and even nonspecific vasodilators such as hydralazine or minoxidil can be helpful.
Clinical trial data demonstrate the need for more intensive blood pressure reduction particularly in patients with diabetes, proteinuria (>1 g/d), or those who are of African-American descent. An systolic blood pressure of 125 mmHg or less is ideal. Consequently, most patients with hypertension and renal disease will require a minimum of three medications, if not more. Preferably, lower doses should be employed in order to avoid toxicity and particularly so with agents that are primarily excreted by the kidney.
In patients with more than 1 g of protein/d in the urine, whether associated with diabetes or not, more intensive blood pressure reduction is required. There is evidence in clinical trials that angiotensin-converting enzyme inhibitors, because of their effects of reducing both blood pressure and proteinuria, may provide an advantage over other commonly used antihypertensive therapies in delaying progression of renal disease in patients with proteinuric nephropathy. Angiotensin type 1 receptor blockers also appear to provide similar reductions in both blood pressure and proteinuria as does the angiotensin-converting enzyme inhibitor. However, long-term studies of these drugs to demonstrate similar renal protective effects have not been completed. However, these drugs, like the angiotensin-converting enzyme inhibitors, remain excellent choices in patients with kidney disease. Nondihydropyridine calcium channel blockers also have additive antihypertensive and antiproteinuric effects with angiotensin-converting enzyme inhibitors, and may be an ideal strategy in many patients. It is also important to realize that reducing dietary salt intake potentiates both the antihypertensive and antiproteinuric properties of angiotensin-converting enzyme inhibitors and nondihydropyridine calcium channel blockers and should be routinely employed as an adjunct therapy in all patients with renal disease.
This post has been viewed 291 times.
Comments are closed.
