RAAS Blockade as First-Line Antihypertensive Therapy among People with CKD (original) (raw)
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Blood Pressure, Hypertension, RAAS Blockade, and Drug Therapy in Diabetic Kidney Disease
Advances in Chronic Kidney Disease, 2014
Type 2 diabetes is the most common cause of CKD and ESRD in the United States and the Western world. Hypertension is prevalent in this cohort, and control of blood pressure is perhaps the most important risk factor to reduce CKD progression. The most recent evidence of blood pressure targets recommended by the Kidney Disease: Improving Global Outcomes and Kidney Disease Outcomes Quality Initiative guideline committees is less than 140/90 mmHg for all patients with CKD Q3 . There is some evidence, for those with 1 g or more of albuminuria, albeit weak, to support a blood pressure target of less than 130/80 mmHg. Multiple studies demonstrate that renin-angiotensin-aldosterone system (RAAS) blockers are important in reducing cardiovascular risk and progression of CKD in those with advanced proteinuric nephropathy. However, there is no evidence that they prevent nephropathy or that reduction in microalbuminuria alone is associated with a slowed nephropathy progression. The purpose of this article is to review the major studies that have evaluated cardiovascular and kidney endpoints in patients with diabetes and the role of RAAS blockers in the treatment of this disease.
High Blood Pressure & Cardiovascular Prevention, 2013
The prevalence of chronic kidney disease, currently estimated to vary between 8 and 12 % in the general population, is steadily rising due to aging and to the ongoing epidemic of hypertension and type 2 diabetes. Even in its early stages, chronic kidney disease entails a greater risk for cardiovascular mortality, and its prevention and treatment is rapidly becoming a key medical issue for many health care systems worldwide. Adequate blood pressure control and reduction of urine protein excretion, preferably obtained by the use of renin-angiotensin-aldosterone system inhibitors, have traditionally been considered the mainstay of therapeutic strategies in patients with renal disease. Given the pivotal role of renin-angiotensin-aldosterone system activity in the pathogenesis and progression of renal and cardiovascular damage, a more profound inhibition of the system, either by the use of multiple agents or by a single agent at high dosage has recently been advocated, especially in the presence of proteinuria. Recent trials, however have failed to confirm the usefulness of this therapeutic approach, at least in unselected patients. This article will critically review the current literature and will discuss the clinical implications of targeting the reninangiotensin-aldosterone system in order to provide the greatest renal protection.
International Journal of Advances in Medicine, 2018
Background: Although dual blockade of the renin-angiotensin-aldosterone system with the combination of an angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker is generally well established as a treatment for nephropathy, this treatment is not fully effective in some patients. Methods: A prospective observational study was done on 600 chronic kidney disease patients during July 2012 to August 2014 to compare the efficacy of triple blockade, double blockade and single blockade of renin-angiotensin-aldosterone system in non diabetic chronic kidney disease. Results: At the end of the study, 24 hours urinary protein excretion rate of group I and group III were compared by using student t-test and p value (0.0268) was found significant. Similarly, on comparing group II and group III, p value (0.0160) was again found significant. Conclusions: Triple blockade of the renin-angiotensin-aldosterone system was effective for the treatment of proteinuria in patients with no...
Hypertension Management in Chronic Kidney Disease: ACEIs/ARBs and Practical Issues
In patients with CKD, hypertension is a common comorbid condition that increases the risk of progression of CKD and the risk of cardiovascular complications. Reduction of BP to less than 140/90 mmHg, slowing the progression of kidney disease and reducing cardiovascular disease (CVD) risk are goals of antihypertensive therapy. However, this BP goal is not attained by the majority of CKD patients. Stringent control of hypertension using a RAAS inhibitorbased treatment regimen is an evidence-based approach to slow the progression of CKD and reduce CVD risk. Most CKD patients require multiple antihypertensive drugs to reduce BP to target level. Clinical evidence indicates that initial fixed-dose RAAS inhibitor-based combination therapy is more effective and more efficient than stepped-care therapy or sequential monotherapy for lowering BP to target levels and reduces the risk of adverse events.
Dual RAAS blockade is desirable in kidney disease: Con
Kidney International, 2010
Dual renin-angiotensin aldosterone (RAAS) blockade is associated with higher risk of hyperkalemia and has not been shown, in any outcome trial of validated renal end points, that is, doubling of creatinine, time to dialysis, or death, to be superior over other approaches. It shows promise in advanced proteinuric nephropathy for additional proteinuria reduction. Whether this additional proteinuria reduction translates into meaningful outcomes of chronic kidney disease (CKD) is unknown, as proteinuria change is not a validated surrogate end point. Until we know the answer to this question, only those with very high levels of proteinuria should receive combination RAAS blocking therapy, and they need to be carefully monitored. Such individuals should be evaluated for risk of hyperkalemia and should consider use of a non-dihydropyridine calcium antagonist added to the single RAAS agent as an alternative for proteinuria reduction. This provides a safe and effective option for those patients with advanced nephropathic disease who need additional proteinuria reduction. In all cases other than advanced proteinuric nephropathy, there is no evidence of any positive CKD outcome with dual RAAS blockade. Thus, dual RAAS blockade cannot be recommended for all CKD patients.
Progression of Renal Disease: Renoprotective Specificity of Renin-Angiotensin System Blockade
Clinical Journal of the American Society of Nephrology, 2006
Recent guidelines for management of patients with chronic kidney disease recommend both lower optimal BP targets and agents that block the renin-angiotensin system (RAS) for specific additional BP-independent renoprotection. Although there are other compelling rationales to use RAS blockade in patients with chronic kidney disease, including its antihypertensive effectiveness and ability to counteract the adverse effects of diuretics, a critical review of the available scientific evidence suggests that the specificity of renoprotection that is provided by RAS blockade has been greatly overemphasized. Little evidence of truly BP-independent renoprotection is observed in experimental animal models when ambient BP is assessed adequately by chronic continuous BP radiotelemetry. Although the clinical trial evidence is somewhat stronger, nevertheless, even when interpreted favorably, the absolute magnitude of the BP-independent component of the renoprotection that is observed with RAS blockade is much smaller than what is due to its antihypertensive effects.
Protecting renal function in the hypertensive patient: Clinical guidelines
Amer J Hypertens, 2005
Both the incidence and prevalence of chronic kidney disease (CKD) are increasing in the United States and worldwide. Patients with both diabetes and hypertension have a dramatically increased risk of cardiovascular and renal events, particularly if both conditions are not effectively controlled. Failure to achieve the goals for blood glucose, blood pressure (BP), and lipids is associated with high morbidity from cardiovascular and renal events as well as the high costs of treating these morbid events. There is increasing evidence that cardiovascular events, renal failure, and premature death can be prevented or delayed by earlier identification and treatment of CKD, as well as by taking measures to prevent its onset. A large subgroup of hypertensive patients may be at increased risk for devel-oping CKD and should be targeted for appropriate monitoring and treatment. Not all antihypertensive regimens are equally effective at preserving renal function. Clinical trials indicate that the primary clinical goal in the treatment of patients with CKD is to lower BP to the recommended goal as well as to reduce albuminuria and proteinuria to the lowest levels possible. This is achieved optimally by using agents that block the renin-angiotensin system in concert with other agents that reduce proteinuria and BP. Am J Hypertens 2005;18:112S-119S