ADPKD patients show high blood pressure as early symptom of progression of disease. It is vital to keep blood pressure low as part of steps to slow the disease. Between ACE inhibitors and ARBs, what does the most recent research indicate as to which is the best choice to prescribe as a first line medication for blood pressure control in ADPKD patients who have no other symptoms.
Autosomal dominant polycystic kidney disease (ADPKD) is a multisystemic and progressive disorder characterized by cyst formation and enlargement first of all in the kidney but also possible in other organs (eg, liver, pancreas, spleen).
Management of ADPKD includes the following:
- Control blood pressure: Drugs of choice are ACEIs (eg, captopril, enalapril, lisinopril) or ARBs (eg, valsartan, telmisartan, losartan, irbesartan, candesartan, olmesartan)
Chapman AB, Devuyst O, Eckardt KU, Gansevoort RT, Harris T, Horie S, et al. Autosomal-dominant polycystic kidney disease (ADPKD): executive summary from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2015 Jul. 88 (1):17-27.
Akoh JA. Current management of autosomal dominant polycystic kidney disease. World J Nephrol. 2015 Sep 6. 4 (4):468-79.
One more variant to treatment:
Tolvaptan (Jynarque), a selective vasopressin V2-receptor antagonist, was approved in the U.S. in April 2018 to slow kidney function decline in adults at risk of rapidly progressing ADPKD.
Gansevoort RT, Arici M, Benzing T, Birn H, Capasso G, Covic A, et al. Recommendations for the use of tolvaptan in autosomal dominant polycystic kidney disease: a position statement on behalf of the ERA-EDTA Working Groups on Inherited Kidney Disorders and European Renal Best Practice. Nephrol Dial Transplant. 2016 Mar. 31 (3):337-48
Dear Russ!
In my practice, I am guided only by approved recommendations. Unfortunately, I have no experience with using drugs outside the protocols.
KR,
Elena
No problem, I understand. If you get time, take a look at a few of the studies on the ones I listed and let me know if you have an opinion.
Maybe the following papers will help you:
1. Frederic Rahbari-Oskoui Olubunmi Williams Arlene Chapman.Mechanisms and management of hypertension in autosomal dominant polycystic kidney disease.Nephrology Dialysis Transplantation, Volume 29, Issue 12, 1 December 2014, Pages 2194–2201, https://doi.org/10.1093/ndt/gft513
2. Chapman AB, Stepniakowski K, Rahbari-Oskoui F. Hypertension in Autosomal Dominant Polycystic Kidney Disease. Advances in chronic kidney disease. 2010;17(2):153-163. doi:10.1053/j.ackd.2010.01.001.
3. Sans-Atxer L, Torra R, Fernández-Llama P. Hypertension in autosomal-dominant polycystic kidney disease (ADPKD). Clinical Kidney Journal. 2013;6(5):457-463. doi:10.1093/ckj/sft031.
4. Torres VE, Abebe KZ, Chapman AB, et al. Angiotensin Blockade in Late Autosomal Dominant Polycystic Kidney Disease. The New England journal of medicine. 2014;371(24):2267-2276. doi:10.1056/NEJMoa1402686.
Thanks Dr. Sarhat. Those are good articles. It seems that it is an either/or with ACE vs. ARB as first line. Some of the more recent studies seem to point out some benefits of ARB. It sounds like you are of the opinion that ACE is best as first line based on the articles you sent.
Hi Russ,, ACE inhibitor or ARB are probably first choice for this condition as antihypertensive drugs. However ARB are better in term of BP reduction compared to ACE inhibitor. These agents are better than amlodepine in prevention of progression of renal dysfunction. However it would be interesting to see the efficacy of newer calcium channel blockers like cilnedepine, benidepine and eflonodepine which are renoprotective compared to ACE inhibitor or ARB in prevention of progression of renal dysfunction in polycystic kidney disease. Some well designed study is needed.. Thanks
Yes, I completelly agree with Biswajit!
This class of antihypertensive drug very important in patients with and stage of kidney dysfunction. Of course we need evidence based clinical trials. BR. Elena.
Good BP control is mandatory from the early stage of the disease, especially in those with significant proteinuria. Undoubtedly, ACE inhibitors or ARBs are the drugs of choice. No firm data to prefer one over the other. Overall BP control probably is slightly better with ARBs. But in later stages with significant renal impairment and hyperkalemia, these drugs may have to be reduced or stopped. Limited data with calcium channel blockers not very encouraging. Newer CCBs like Cilnidipine and Efonidipine may be useful though no data is available at present to support that. Tolvaptan has been studied in early stage of the disease and looks promising. Centrally acting drugs and alpha blockers as well as beta blockers can be considered add- on drugs. Even with the best efforts, the patients progress to ESRD over a span of time.
Dear George, you are right!
All patients have the right to life. And we must use all possible and impossible options.
Therefore your opinion is very important.
BR,
Elena.
Thank you Elena. As you have rightly pointed out, hypertension is difficult to control in many such patients. Different combinations may have to be tried.
RAAS blockers are recommended as first-line therapy to treat hypertension in patients with ADPKD. And it is evident that ACE-I/ARB combination therapy provides no benefit over ACE-I alone.
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