Treatment of Hypertensive Patients with Chronic Renal Insufficiency

  • Samuel Spitalewitz
  • Jerome G. Porush
Part of the Current Clinical Practice book series (CCP)


The prevalence of hypertension in patients with chronic renal insufficiency (CRI) from all causes increases linearly as renal function deteriorates, reaching approx 95% as patients approach end-stage renal disease (ESRD) (1–3). There is now substantial evidence that controlling blood pressure (BP) will slow the inexorable decline in renal function in patients with CRI (4). Nevertheless, at a time when morbidity and mortality from cardiovascular disease is declining, the incidence of ESRD is increasing dramatically, particularly in African Americans, the elderly, and diabetics (5). There is no single explanation for this fact, but pertinent issues are as follows (6, 7):
  1. 1.

    Should the general therapeutic approach to hypertension (nonpharmacologic and/or pharmacologic) differ in patients with CRI vs essential hypertensive patients without renal insufficiency?

  2. 2.

    Will lowering BP to levels below current standards (140/90 mmHg; mean arterial pressure [MAP] = 107) better preserve renal function without increasing adverse consequences?

  3. 3.

    Are there specific classes of antihypertensive drugs that are renoprotective over and above their effect on BP?



Diabetic Nephropathy Chronic Renal Insuf Urinary Protein Excretion Joint National Committee Goal Blood Pressure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Vertes V, Cangiano JL, Berman LB, Gould A (1969) Hypertension in end-stage renal disease. N Engl J Med 280: 978–981.PubMedCrossRefGoogle Scholar
  2. 2.
    Buckalew VM Jr, Berg RL, Want SR, Porush JG, Ranch S, Schulman G (1996) Prevalence of hypertension in 1,795 subjects with chronic renal disease: The Modification of Diet in Renal Disease Study baseline cohort. Am J Kidney Dis 28: 811–821.PubMedCrossRefGoogle Scholar
  3. 3.
    Spitalewitz S, Porush JG (1994) Treatment of hypertensive patients with chronic renal insufficiency. In: Izzo JL Jr, Black HR, eds. Hypertension Primer, vol. E29, Dallas: American Heart Association, pp. 354–357.Google Scholar
  4. 4.
    National High Blood Pressure Education Program Group (1996) 1995 Update of the working group reports on chronic renal failure and renovascular hypertension. Arch Intern Med 156: 1938–1947.Google Scholar
  5. 5.
    (1994) US Renal Data System: USRDS 1994 Annual Data Report,Bethesda MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.Google Scholar
  6. 6.
    Weir MW, Dworkin LD (1998) Antihypertensive drugs, dietary salt, and renal protection: how long should you go and with which therapy? Am J Kidney Dis 32: 1–22.PubMedCrossRefGoogle Scholar
  7. 7.
    Porush JG (1998) Hypertension and chronic renal failure: the use of ACE-inhibitors. Am J Kidney Dis 31: 177–184.PubMedCrossRefGoogle Scholar
  8. 8.
    Bakris GL, Weir MR (1996) Salt intake and reductions in the arterial pressure and proteinuria. Am J Hypertens 9: 200S - 206S.PubMedCrossRefGoogle Scholar
  9. 9.
    Suki WN (1997) Use of diuretics in chronic renal failure. Kidney Int 51: (Suppl. 59)S33–S35.Google Scholar
  10. 10.
    Fliser D, Schroter M, Neubeck M, Ritz E (1994) Coadministration of thiazides increases the efficacy of loop diuretics even in patients with advanced renal failure. Kidney Int 46: 482–488.PubMedCrossRefGoogle Scholar
  11. 11.
    Oates J (1995) Antihypertensive agents and the drug therapy of hypertension. In: Handman JG, Gilman AG, Limbird LE, eds. Goodman 0000 Gilman’s The Pharmacological Basis of Therapeutics, 9th ed., New York: McGraw Hill, pp. 780–808.Google Scholar
  12. 12.
    Joint National Committee (1997) The Sixth Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. Arch Intern Med 157: 2413–2446.Google Scholar
  13. 13.
    Reiser IW, Pallan TM, Spitalewitz S (1998) How to treat renovascular hypertension: medical therapy versus revascularization. J Crit Illness 13: 409–424.Google Scholar
  14. 14.
    Schulman NB, Ford CE, Hall WD, Blaufox MD, Simon D, Langford HG, Schneider KA (1989) Prognostic value of serum creatinine and effect of treatment of hypertension on renal function: results from the hypertension detection and follow-up program. The Hypertension Detection and Follow-up Program Cooperative Group. Hypertension 13 (Suppl. 1): 80–93.CrossRefGoogle Scholar
  15. 15.
    Walker GW, Neaton JD, Cutler JA, Neuwirth R, Cohen JD, for the MRFIT Research Group (1992) Renal function change in hypertensive members of the Multiple Risk Factor Intervention Trial: racial and treatment effects. JAMA 268: 3085–3091.Google Scholar
  16. 16.
    Tierney WM, McDonald CJ, Luft FC (1989) Renal disease in hypertensive adults: effect of race and type II diabetes mellitus. Am J Kidney Dis 13: 485–493.PubMedGoogle Scholar
  17. 17.
    Perry HM, Miller JP, Formoff JR, Baty JD, Sambhi MP, Rutan G, Moskowitz DW, Carmody SE (1995) Early predictors of 15-year end-stage renal disease in hypertensive patients. Hypertension 25: 587–594.PubMedCrossRefGoogle Scholar
  18. 18.
    Brazy PC, Fitzwilliam JF (1990) Progressive renal disease: role of race and antihypertensive medications. Kidney Int 37: 1113–1119.PubMedCrossRefGoogle Scholar
  19. 19.
    Locatelli F, Marcelli D, Comelli M, Alberti D, Graziani G, Buccianti G, Redaelli B, Giangrande A, Northern Italian Cooperative Study Group (1996) Proteinuria and blood pressure as casual components of progression to end-stage renal failure. Nephrol Dial Transplant 11:461–467.Google Scholar
  20. 20.
    Rostand SG, Brown G, Kirk KA, Rutsky EA, Dustan HP (1969) Renal insufficiency in treated essential hypertension. N Engl J Med 320: 684–688.CrossRefGoogle Scholar
  21. 21.
    Rosansky SJ, Hoover DR, King L, Gibson J (1990) The association of blood pressure levels and change in renal function in hypertensive and non-hypertensive subjects. Arch Intern Med 150: 2073–2076.PubMedCrossRefGoogle Scholar
  22. 22.
    Wright JT, Kusek JW, Toto RD, Lee JY, Agodoa LY, Randall OS, Kirk KA, Glassock R (1996) Design and baseline characteristics of participants in the African-American Study of Kidney Disease and Hypertension (AASK) pilot study. Contr Clin Trials 17(Suppl. 4)3S–16S.Google Scholar
  23. 23.
    Klahr S, Levey AS, Beck GJ, Cagguila AW, Hunsiker L, Kusek JW, Striker G (1994) The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med 330: 877–884.PubMedCrossRefGoogle Scholar
  24. 24.
    Wight JP, Brown CB, el Nahas AM (1993) Effect of control of hypertension on progressive renal failure. Clin Nephrol 39: 305–311.PubMedGoogle Scholar
  25. 25.
    Alvestrand A, Gutierrez A, Bucht H. Bergstrom J (1998) Reduction in blood pressure retards the progression of chronic renal failure in man. Nephrol Dial Transplant 3: 624–631.Google Scholar
  26. 26.
    Bergstrom J, Alvestrand A, Bucht A, Gutierrez A (1986) Progression of chronic renal failure in man is retarded with more frequent clinical follow-ups and better blood pressure control. Clin Nephrol 25: 1–6.PubMedGoogle Scholar
  27. 27.
    Zucchelli P, Zuccalà A, Borghi M, Fusaroli M, Sasdelli M, Stallone C, Sanna G, Gaggi R (1992) Long-term comparison between captopril and nifedipine in the progression of renal insufficiency. Kidney Int 42: 452–458.PubMedCrossRefGoogle Scholar
  28. 28.
    Lewis EJ, Hunsicker LG, Bain RP, Rohde RD, for the Collaborative Study Group (1993) The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. N Engl J Med 329: 1456–1462.Google Scholar
  29. 29.
    Mogensen CE (1976) Progression of nephropathy in long-term diabetics with proteinuria and effect of initial antihypertensive treatment. Scand J Clin Lab Invest 36: 383–388.PubMedCrossRefGoogle Scholar
  30. 30.
    Dillon JJ (1993) The quantitative relationship between treated blood pressure and progression of diabetic renal disease. Am J Kidney Dis 22: 798–802.PubMedGoogle Scholar
  31. 31.
    Walker WG (1993) Hypertension-related renal injury: a major contributor to end-stage renal disease. Am J Kidney Dis 22: 164–173.PubMedGoogle Scholar
  32. 32.
    Parving H-H, Smidt UM, Hommel E, Mathiesen ER, Rossing P, Nielson F, Gall MA (1993) Effective antihypertensive treatment postpones renal insufficiency in diabetic nephropathy. Am J Kidney Dis 22: 188–195.PubMedGoogle Scholar
  33. 33.
    Mathiesen ER, Hommel E, Giese J, Parving H-H (1991) Efficacy of captopril in postponing nephropathy in nomotensive insulin dependent diabetic patients with microalbuminuria. BMJ 303: 81–87.PubMedCrossRefGoogle Scholar
  34. 34.
    Kasiske BL, Kalil RSN, Ma JZ, Liao M, Keane WM (1993) Effects of antihypertensive therapy on the kidney in patients with diabetes: a meta-regression analysis. Ann Intern Med 118: 129–138.PubMedGoogle Scholar
  35. 35.
    Hebert LA, Bain RP, Verne D, Cottran D, Whittier FC, Tolchin N, Rhode RD, Lewis EJ, for the Collaborative Study Group (1994) Remission of nephrotic range proteinuria in type I diabetes. Kidney Int 46: 1688–1693.Google Scholar
  36. 36.
    Anderson S, Rennke HG, Brenner BM (1986) Therapeutic advantage of converting enzyme inhibitors in arresting progressive renal disease associated with systemic hypertension in the rat. J Clin Invest 77: 1993–2000.PubMedCrossRefGoogle Scholar
  37. 37.
    Keane WF, Anderson S, Aurell M, de Zeeuw D, Narins RG, Povar G (1989) Angiotensin converting enzyme inhibitors and progressive renal insufficiency: current experience and future directions. Ann Intern Med 111: 503–516.PubMedGoogle Scholar
  38. 38.
    Hannedouche T, Landais P, Goldfarb B, Esper NE, Fournier A, Galin M, Durand B, Chanard J, Mignon F, Suc J-M, Grünfeld J-P (1994) Randomized controlled trial of enalapril and 3-blockers in non-diabetic chronic renal failure. BMJ 309: 833–837.PubMedCrossRefGoogle Scholar
  39. 39.
    Maschio G, Alberti D, Janin G, for the Angiotensin-Converting-Enzyme Inhibition in Progressive Renal Insufficiency Study Group (1996) Effect of the angiotensin-converting enzyme inhibitor benazepril on the progression of chronic renal insufficiency. N Engl J Med 334: 939–945.Google Scholar
  40. 40.
    Gruppo Italiano di Studi Epidemiologici in Nefrologia (1997) Randomized placebo-controlled trial of effect of ramipril on decline in glomerular filtration rate and risk of terminal renal failure in proteinuric, non-diabetic nephropathy. Lancet 349: 1857–1863.Google Scholar
  41. 41.
    Ruggenenti P, Perna A, Mosconi L, Massimo M, Pisoni R, Gaspari F, Remuzzi G, on behalf of the “Gruppo Italiano di Studi Epidemiologici in Nefrologia” (GISEN) (1997) Proteinuria predicts and-stage renal failure in non-diabetic chronic nephropathies. Kidney Im’ 52(Suppl. 63):S-54-S-57.Google Scholar
  42. 42.
    Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G, on behalf of Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN) (1998) Renal function; and requirement for dialysis in chronic nephropathy patients on longterm ramipril: REIN follow-up trial. Lancet 352: 1252–1256.Google Scholar
  43. 43.
    Giatras I, Lau J, Levey AS, for the Angiotensin-Converting Enzyme Inhibition and Progressive Renal Disease Study Group (1997) Effect of angiotensin-converting enzyme inhibitors on the progression of non-diabetic renal disease: a meta-analysis of randomized trials. Ann Intern Med 127: 337–345.Google Scholar
  44. 44.
    Dongall ML, Moore WV (1992) Effect of angiotensin-converting enzyme inhibition on renal function and albuminuria in normotensive type I diabetic patients. Diabetes 41: 62–67.CrossRefGoogle Scholar
  45. 44.
    Ravid M, Savin H, Jutrin I, Bental T, Lishner M (1993) Long-term stabilization effect of angiotensin-converting enzyme inhibitor on plasma creatinine and on proteinuria in normotensive type II diabetic patients. Ann Intern Med 118:577–581.Google Scholar
  46. 46.
    Romero R, Salinas I, Lucas A, et al. (1993) Renal function changes in microalbuminuric normotensive type II diabetic patients treated with angiotensin-converting enzyme inhibitors. Diabetes Care 16: 597–600.PubMedCrossRefGoogle Scholar
  47. 47.
    Viberti G, Mogensen CE, Groop LC, et al. (1994) Effect of captopril on progression to clinical proteinuria in patients with insulin dependent diabetes mellitus and microalbuminuria. JAMA 271: 275–279.PubMedCrossRefGoogle Scholar
  48. 48.
    Weir MR (1996) Angiotensin-II receptor antagonists: a new class of antihypertensive agents. Am Fam Physician 53: 589–594.PubMedGoogle Scholar
  49. 49.
    Gansevoort RT, de Zeeuw D, Shahinfar S, Redfield A, de Jong PE (1994) Effects of the angiotensin II antagonist losartan in hypertensive patients with renal disease. J Hypertens 12(Suppl. 2)S37–S42.Google Scholar
  50. 50.
    Ichikawa I (1996) Will angiotensin II receptor antagonists be renoprotective in humans? Kidney Int 50: 684–692.PubMedCrossRefGoogle Scholar
  51. 51.
    Gansevoort RT, de Zeeuw D, de Jong PE (1994) Is the antiproteinuric effect of ACE inhibition mediated by interference in the renin-angiotensin system? Kidney Int 45: 861–867.PubMedCrossRefGoogle Scholar
  52. 52.
    Epstein M (1998) Calcium antagonists and the progression of chronic renal failure Curr Opin Nephrol Hypertens 7: 171–177.PubMedCrossRefGoogle Scholar
  53. 53.
    Bakris GL, Barnhill BW, Sadler R (1992) Treatment of arterial hypertension in diabetic humans: importance of therapeutic selection. Kidney Int 41: 912–919.PubMedCrossRefGoogle Scholar
  54. 54.
    Velussi M, Brocco E, Frigato F, Zolli M, Muollo B, Malloll M (1996) Effects of cilazapril and amlodipine on kidney function in hypertensive NIDDM patients. Diabetes 45: 216–222.PubMedCrossRefGoogle Scholar
  55. 55.
    Slataper R, Vicknair N, Sadler R, Bakris GL (1993) Comparative effects of different antihypertensive treatments on progression of diabetic kidney disease. Arch Intern Med 153: 973–980.PubMedCrossRefGoogle Scholar
  56. 56.
    Bakris GL, Mangrum A, Copley JB, Sadler R (1997) Effect of calcium channel or 13-blockade on the progression of diabetic nephropathy in African Americans. Hypertension 29: 744–750.PubMedCrossRefGoogle Scholar
  57. 57.
    ter Wee PM, De Micheli AG, Epstein M (1994) Effects of calcium antagonists on renal hemodynamics and progression of non-diabetic chronic renal disease. Arch Intern Med 154: 1185–1202.PubMedCrossRefGoogle Scholar
  58. 58.
    Rossing P, Tarnow L, Boelskifter S, Jensen BR, Nielsen FS, Parving H-H (1997) Differences between nisoldipine and lisinopril on glomerular filtration rates and albuminuria in hypertensive IDDM patients with diabetic nephropathy during the first year of treatment. Diabetes 46: 481–487.PubMedCrossRefGoogle Scholar
  59. 59.
    Gansevoort RT, Sluiter WJ, Hemmelder MH, et al. (1995) Antiproteinuric effect of blood-pressure-lowering agents: a meta-analysis of comparative trials. Nephrol Dial Transplant 10: 1963–1974.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2001

Authors and Affiliations

  • Samuel Spitalewitz
  • Jerome G. Porush

There are no affiliations available

Personalised recommendations