Current Hypertension Reports

, Volume 10, Issue 5, pp 367–373

Hypertension management in patients with chronic kidney disease



Hypertension is one of the major risk factors for the development and progression of chronic kidney disease. The loss of renal function leads to impaired renal autoregulation and renders the kidney vulnerable to the damaging effects of uncontrolled hypertension. Mounting evidence indicates that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers slow the progression of chronic kidney disease through effects beyond lowering blood pressure. Studies are needed to determine whether high doses of the single agent or combination therapy is most effective in providing renal protection. Urinary protein excretion is a useful tool for monitoring and titrating therapy to maximize renal protection. Changes in the serum creatinine concentration and hyperkalemia are complications of antihypertensive therapy in patients with chronic kidney disease that can be successfully managed to allow continued use of renin-angiotensin blockade.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    National Kidney Foundation: K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002, 39(2 Suppl 1):S1–S266.Google Scholar
  2. 2.
    Go AS, Chertow G, Fan D, et al.: Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004, 351:1296–1305.PubMedCrossRefGoogle Scholar
  3. 3.
    Kidney Disease Outcomes Quality Initiative (K/DOQI): K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis 2004, 43(5 Suppl 1):S1–S290.Google Scholar
  4. 4.
    Weiner D, Tighiouart H, Levey A, et al.: Lowest systolic blood pressure in associated with stroke in stages 3 to 4 chronic kidney disease. J Am Soc Nephrol 2007, 18:960–966.PubMedCrossRefGoogle Scholar
  5. 5.
    Ninomiya T, Perkovic V, Gallagher M, et al.: Lower blood pressure and risk of recurrent stroke in patients with chronic kidney disease: PROGRESS trial. Kidney Int 2008, 73:963–970.PubMedCrossRefGoogle Scholar
  6. 6.
    Palmer BF: Impaired renal autoregulation: implications for the genesis of hypertension and hypertension-induced renal injury. Am J Med Sci 2001, 321:388–400.PubMedCrossRefGoogle Scholar
  7. 7.
    Thompson A, Pickering T: The role of ambulatory blood pressure monitoring in chronic and end-stage renal disease. Kidney Int 2006, 70:1000–1007.PubMedCrossRefGoogle Scholar
  8. 8.
    Svensson P, de Faire U, Sleight P, et al.: Comparison of the effects of ramipril on ambulatory and office blood pressures. A HOPE substudy. Hypertension 2001, 38:E28–E32.PubMedCrossRefGoogle Scholar
  9. 9.
    Griffin K, Bidani A: Progression of renal disease: renoprotection specificity of rennin-angiotensin system blockade. Clin J Am Soc Nephrol 2006, 1:1054–1065.PubMedCrossRefGoogle Scholar
  10. 10.
    Alicic R, Tuttle K: Do agents that block the RAS truly offer renoprotective effects in early stage, nonproteinuric nephropathy? Curr Hypertens ReP 2007, 9:393–402.PubMedCrossRefGoogle Scholar
  11. 11.
    Palmer BF: Disturbances in renal autoregulation and the susceptibility to hypertension-induced chronic kidney disease. Am J Med Sci 2004, 328:330–343.PubMedGoogle Scholar
  12. 12.
    Hsu CY, Lin F, Vittinghoff E, et al.: Racial differences in the progression from chronic renal insufficiency to end-stage renal disease in the United States. J Am Soc Nephrol 2003, 14:2902–2907.PubMedCrossRefGoogle Scholar
  13. 13.
    Stehman-Breen C, Gillen D, Steffes M, et al.: Racial differences in early-onset renal disease among young adults: the coronary artery risk development in young adults (CAR-DIA) study. J Am Soc Nephrol 2003, 14:2352–2357.PubMedCrossRefGoogle Scholar
  14. 14.
    Palmer BF: Renal dysfunction complicating treatment of hypertension. N Engl J Med 2002, 347:1256–1261.PubMedCrossRefGoogle Scholar
  15. 15.
    Palmer BF: Proteinuria as a therapeutic target in patients with chronic kidney disease. Am J Nephrol 2007, 27:287–293.PubMedCrossRefGoogle Scholar
  16. 16.
    Lea J, Greene T, Hebert L, et al.: The relationship between the magnitude of proteinuria reduction and risk of endstage renal disease. Arch Intern Med 2006, 165:947–953.CrossRefGoogle Scholar
  17. 17.
    Parving HH, Smidt UM, Hommel E, et al.: Effective antihypertensive treatment postpones renal insufficiency in diabetic nephropathy. Am J Kidney Dis 1993, 22:188–195.PubMedGoogle Scholar
  18. 18.
    Sarafidis P, Khosla N, Bakris G: Antihypertensive therapy in the presence of proteinuria. Am J Kidney Dis 2007, 49:12–26.PubMedCrossRefGoogle Scholar
  19. 19.
    Peterson JC, Adler S, Burkart JM, et al.: Blood pressure control, proteinuria, and the progression of renal disease. The Modification of Diet in Renal Disease Study. Ann Intern Med 1995, 123:754–762.PubMedGoogle Scholar
  20. 20.
    Jafar TH, Stark PC, Schmid CH, et al.: Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med 2003, 139:244–252.PubMedGoogle Scholar
  21. 21.
    Matcher D, McCrory D, Orlando L, et al.: Systematic review: comparative effectiveness of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for treating essential hypertension. Ann Intern Med 2008, 148:16–29.Google Scholar
  22. 22.
    Kunz R, Friedrich C, Wolbers M, Mann J: Meta-analysis: effect of monotherapy and combination therapy with inhibitors of the renin-angiotensin system on proteinuria in renal disease. Ann Intern Med 2008, 148:30–48.PubMedGoogle Scholar
  23. 23.
    Bakris GL, Weir MR, Secic M, et al.: Differential effects of calcium antagonist subclasses on markers of nephropathy progression. Kidney Int 2004, 65:1991–2002.PubMedCrossRefGoogle Scholar
  24. 24.
    Wilmer WA, Hebert LA, Lewis EJ, et al.: Remission of nephrotic syndrome in type 1 diabetes: long-term follow-up of patients in the Captopril Study. Am J Kidney Dis 1999, 34:308–314.PubMedCrossRefGoogle Scholar
  25. 25.
    Jones-Burton C, Mishra SI, Fink JC, et al.: An in-depth review of the evidence linking dietary salt intake and progression of chronic kidney disease. Am J Nephrol 2006, 26:268–275.PubMedCrossRefGoogle Scholar
  26. 26.
    Weir MR: Is it the low-protein diet or simply the salt restriction? Kidney Int 2007, 71:188–190.PubMedCrossRefGoogle Scholar
  27. 27.
    Buter H, Hemmelder MH, Navis G, et al.: The blunting of the antiproteinuric efficacy of ACE inhibition by high sodium intake can be restored by hydrochlorothiazide. Nephrol Dial Transplant 1998, 13:1682–1685.PubMedCrossRefGoogle Scholar
  28. 28.
    Bakris GL, Smith A: Effects of sodium intake on albumin excretion in patients with diabetic nephropathy treated with long-acting calcium antagonists. Ann Intern Med 1996, 125:201–204.PubMedGoogle Scholar
  29. 29.
    Esnault VL, Ekhlas A, Delcroix C, et al.: Diuretic and enhanced sodium restriction results in improved antiproteinuric response to RAS blocking agents. J Am Soc Nephrol 2005, 16:474–481.PubMedCrossRefGoogle Scholar
  30. 30.
    Palmer BF: Supratherapeutic doses of angiotensin receptor blockers to decrease proteinuria in patients with chronic kidney disease. Am J Nephrol 2008, 28:381–390.PubMedCrossRefGoogle Scholar
  31. 31.
    MacKinnon M, Shurraw S, Akbari A, et al.: Combination therapy with an angiotensin receptor blocker and an ACE inhibitor in proteinuric renal disease: a systematic review of the efficacy and safety data. Am J Kidney Dis 2006, 48:8–20.PubMedCrossRefGoogle Scholar
  32. 32.
    Nakao N, Yoshimura A, Morita H, et al.: Combination treatment of angiotensin-II receptor blocker and angiotensin-converting-enzyme inhibitor in non-diabetic renal disease (COOPERATE): a randomised controlled trial. Lancet 2003, 361:117–124.PubMedCrossRefGoogle Scholar
  33. 33.
    Bakris G, Ruilope L, Locatelli F, et al.: Treatment of microalbuminuria in hypertensive subjects with elevated cardiovascular risk: results of the improve trial. Kidney Int 2007, 72:879–885.PubMedCrossRefGoogle Scholar
  34. 34.
    Makino H, Haneda M, Babazono T, et al.: Prevention of transition from incipient to overt nephropathy with telmisartan in patients with type 2 diabetes. Diabetes Care 2007, 30:1577–1578.PubMedCrossRefGoogle Scholar
  35. 35.
    Bomback A, Kshirsagar A, Amamoo M, Klemmer P: Change in proteinuria after adding aldosterone blockers to ACE inhibitors or angiotensin receptor blockers I CKD: a systematic review. Am J Kidney Dis 2008, 51:199–211.PubMedCrossRefGoogle Scholar
  36. 36.
    Gradman A, Pinto R, Kad R: Current concepts: renin inhibition in the treatment of hypertension. Curr Opin Pharmacol 2008, 8:120–126.PubMedCrossRefGoogle Scholar
  37. 37.
    Persson F, Rossing P, Schjoedt K, et al.: Time course of the antiproteinuric and antihypertensive effects of direct rennin inhibition in type 2 diabetes. Kidney Int 2008, 73:1419–1425.PubMedCrossRefGoogle Scholar
  38. 38.
    Feldt S, Maschke U, Dechend R, et al.: The putative (pro)renin receptor blocker HRP fails to prevent (pro)renin signaling. J Am Soc Nephrol 2008, 19:743–748.PubMedCrossRefGoogle Scholar
  39. 39.
    Palmer BF: Managing hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system. N Engl J Med 2004, 351:585–592.PubMedCrossRefGoogle Scholar
  40. 40.
    Hou F, Zhang X, Zhang G, et al.: Efficacy and safety of benazepril for advanced chronic renal insufficiency. N Engl J Med 2006, 354:131–140.PubMedCrossRefGoogle Scholar

Copyright information

© Current Medicine Group LLC 2008

Authors and Affiliations

  1. 1.Department of Medicine, Division of NephrologyUniversity of Texas Southwestern Medical CenterDallasUSA

Personalised recommendations