Week 4: Medication Strategies for Blood Pressure Control in CKD Patients

Vishruth P -

Hi everyone! This week, I wanted to focus on how doctors prescribe blood pressure medications to patients with CKD to delay kidney complications and prevent the need for dialysis. Last week, I briefly mentioned two types of medications that are commonly used: ACEIs and ARBs. This week, I’d like to go into detail and also discuss some other medicines that are prescribed. I also mentioned last week that not all antihypertensive medications work the same way for CKD patients, so I wanted to dig deeper into how nephrologists choose the best treatment plans.

Key Medication Classes for CKD Patients

  1. Angiotensin-converting-enzyme inhibitors (ACE Inhibitors, ACEIs) & Angiotensin Receptor Blockers (ARBs)
    • As I mentioned last week, these are the first-line medications for CKD patients with hypertension, meaning they are the initial treatment option prescribed. They work by relaxing blood vessels and reducing pressure in the glomeruli, protecting kidney function.
    • ACEIs and ARBs are drugs that block the action of the hormone angiotensin II. ACEIs block the production of angiotensin II, whereas ARBs block it from binding to its receptors.
    • Studies show that ACEIs and ARBs delay the progression of CKD and decrease proteinuria (excess protein in urine, an indicator of kidney damage).
    • However, they should be monitored carefully because they are capable of elevating potassium to a level that is toxic to certain patients.
  2. Diuretics (Water Pills)
    • Diuretics remove excess fluid caused by CKD, leading to a decrease in blood pressure.
    • Thiazide diuretics, such as hydrochlorothiazide, are helpful during the early stages of CKD. Loop diuretics, such as furosemide, are employed during later stages of CKD when kidney function deteriorates.
  3. Calcium Channel Blockers (CCBs)
    • These help to dilate blood vessels and are often used with ACEIs or ARBs if further blood pressure control is needed.
    • Dihydropyridine CCBs, like amlodipine, are commonly employed since they don’t interfere with kidney function.
  4. Beta-Blockers & Aldosterone Antagonists
    • Beta-blockers help CKD patients with heart disease but are not first-line treatments for kidney protection.
    • Aldosterone antagonists (like spironolactone) may help in resistant hypertension but require potassium monitoring.

One of the most challenging aspects of CKD treatment is that CKD patients often require multiple medications to control blood pressure. Some take 3 to 4 medications to maintain their blood pressure below 130/80 mmHg. But finding the optimal balance between how effectively the medicine functions and the side effects (such as issues with electrolytes) makes the treatment highly individualized.

Next week, I will discuss how to control blood pressure in CKD without medications. This will be through dietary changes, physical exercise, and other lifestyle modifications, so make sure to look out for that post!

Thanks,
Vishruth

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    bhavitha_s
    Hi Vishi! You talked about many medications in this post, and you also mentioned that some people take 3-4 medications to keep their BP in check. Are there any medications that a patient should not take when prescribed the drugs mentioned above? I was looking into it and apparently ACE inhibitors can interact with NSAIDs like ibuprofen. Do you know of anything else like that?
    March 7, 2025 at 8:18 pm - Reply
    valerie_p
    Hi Vishi, great post! It seems like any of these potential treatments require monitoring potassium levels, so I'm just wondering, how is it monitored? Like just through frequent blood tests or some other way?
    March 10, 2025 at 11:05 am - Reply
      vishruth_p
      Hi Valerie, that's a great question! You're right - potassium monitoring is crucial for CKD patients, especially those taking medications like ACE inhibitors, ARBs, or potassium-sparing diuretics. The most common method is through routine blood tests, where doctors measure potassium levels along with other key markers like sodium, creatinine, and eGFR (estimated glomerular filtration rate) to assess kidney function. For CKD patients starting a new medication that can affect potassium, blood tests are often done more frequently at first - sometimes every 1-2 weeks - to ensure potassium levels remain stable. In addition to blood tests, doctors may also monitor electrocardiograms (ECGs) in severe cases since abnormal potassium levels can affect heart rhythm. Patients are sometimes advised to track their diet carefully as well, since potassium-rich foods can further influence levels.
      March 11, 2025 at 3:18 pm - Reply
    jessie_z
    Hi Vishi! Considering how some patients have to take 3 to 4 medications, are there any potential advancements being made that could allow them to only take one and still maintain proper blood pressure?
    March 17, 2025 at 9:22 am - Reply
      vishruth_p
      Hi Jessie, great question! Currently, one of the major areas of research in hypertension and CKD treatment is the development of fixed-dose combination (FDC) pills that combine multiple antihypertensive drugs into a single pill. Some combinations already exist, such as ACE inhibitors with diuretics or calcium channel blockers, but researchers are trying to develop better single-pill combinations that are personalized, meet patients' requirements, and lower the side effect profile.
      March 18, 2025 at 9:58 pm - Reply

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