KDIGO guidelines indicate ACEi or ARBs for CKD with elevated albuminuria, but do not indicate any particular drug for CKD with normoalbuminuria. What about primary prevention of CKD by preventing appearance of 'microalbumimuria' by means of blocking RAS?
Hi Manuel
Lately it was signaled in the literature that beta blockers should be preferred as anti hypertensive agents in CKD patient population- especiall in prevention of major CV events and regression of LV hypertrophy. Literature data support the use of ACEI/ARBI for diminishing microalbuminuria.
I'd imagine it should also be addressed on whether this person truely does have CKD or is it more of an age related phenomenon/eGFR measurement quirk. The above beta-blocker article is for end-stage kidney patients on haemodialysis so cannot be extrapolated to CKD without albuminuria. I would suggest follow general medical guidelines for hypertensive management, unless the person has microalbuminuria and is diabetic, then they would certainlyrequire an ACE I if no contraindications. There is no strong evidence for preventitive RAS blocking to prevent microalbuminuria. There's lots of trials ongoing looking at the RAS to prevent early such as the STOP_CKD study with the use of spironolactone in early CKD to stop the early cardiovascular changes such as increased LV mass and arterial stiffness developing
Since atherosclerosis and other cardiovascular comorbidities associated with CKD, ACE-Is and preferentially ARBs may be beneficial even for non-proteinuric hypertensive patients. Diabetic hypertensive patients are good candidates for such therapeutic approach, for sure in the presence of proteinuria but also in non-proteinuric hypertensive diabetic individuals.
Non-proteinuric CKD can be due to bilateral atherosclerotic renal artery stenosis causing Ischemic nephropathy . This is a macrovascular complication due to atherosclerosis , which is different from microvascular renal complication of diabetic nephropathy . ACEI & ARB are valuable in microvascular renal complications . But in macrovascular renal disease , these drugs worsen CKD by altering renal hemodynamics . A rise of serum creatinine in patients with CKD should raise suspicion of Ischemic nephropathy . Calcium channel blockers & beta blockers are better choices in these group of patients .
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