Multiple trials have shown the benefits of blood pressure control in renal disease, particularly in patients with proteinuria, where ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) have particularly beneficial effects in protecting long term kidney function.
These apply to all stages of CKD.
- Proteinuria low: ACR<70 or PCR<100 - Target blood pressure <140/90 (NICE suggests 130-139/90)
- Proteinuria high: ACR>70 or PCR>100: - Target blood pressure <130/80 (NICE suggests 120-129/80)
ACE inhibitors or ARBs should be included in:
- Patients with urinary ACR>30 or PCR>50
- Diabetics with microalbuminuria
Starting and monitoring therapy with ACE inhibitors or ARBs
Check serum creatinine and potassium
- Before starting therapy (do not start if K above normal range)
- After 1-2 weeks
- After subsequent dose increases
If creatinine rises >30% or GFR fall >25%, repeat tests, stop drug and consider other causes including volume depletion, NSAID use. If no other explanation, consider investigation for renal artery stenosis.
Do not discontinue for lesser changes in eGFR/creatinine, some change is expected.
If K>6, stop drugs that may be contributing, e.g. NSAIDs, potassium-retaining diuretics, and check diet (especially 'LoSalt' which is potassium chloride). If hyperkalaemia persists the ACE inhibitor or ARB should be stopped.
Modest stable hyperkalaemia may be prefereable to discontinuing a valuable therapy.
It is appropriate to stop ACEi/ARB at times of high risk of acute renal failure (for example, acute volume depletion) and resume therapy later.
Information for patients
Blood pressure control is critically important in preventing further kidney deterioration in many patients with CKD, and in protecting against damage to heart and arteries.
Blood pressure in renal disease (EdREN) and the links from the foot of that page are useful.