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Antihypertensive Therapy and Progression of Nondiabetic Chronic Kidney Disease in Adults

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Text of Antihypertensive Therapy and Progression of Nondiabetic Chronic Kidney Disease in Adults

  • Official reprint from UpToDatewww.uptodate.com 2015 UpToDate

    AuthorsJohannes FE Mann, MDGeorge L Bakris, MD

    Section EditorGary C Curhan, MD, ScD

    Deputy EditorJohn P Forman, MD, MSc

    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice,diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professionalregarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use2015 UpToDate, Inc.

    Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults

    All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: May 2015. | This topic last updated: Oct 27, 2014.

    INTRODUCTION Progression of chronic kidney disease (CKD), as defined by a reduction in the glomerularfiltration rate (GFR), occurs at a variable rate, ranging from less than 1 to more than 12 mL/min per 1.73 m per year,depending upon the level of blood pressure control, the degree of proteinuria, the previous rate of GFR decline, andthe underlying kidney disease, including diabetes [1-5].

    There are two major components to slowing the rate of progression of CKD: treatment of the underlying disease, ifpossible; and treatment of secondary factors that are predictive of progression, such as elevated blood pressure andproteinuria. (See 'Importance of proteinuria and blood pressure control' below.)

    The clinical trials evaluating antihypertensive therapy in nondiabetic CKD and our recommendations for choice oftherapy as well as treatment goals will be reviewed here. The animal studies that provided the mechanisms andrationale for the clinical trials, the treatment of diabetic nephropathy, and general issues related to the treatment ofhypertension in patients with CKD are discussed separately. (See "Antihypertensive therapy and progression ofchronic kidney disease: Experimental studies" and "Treatment of diabetic nephropathy" and "Overview ofhypertension in acute and chronic kidney disease".)

    The approach to slowing the progression of CKD in children is discussed elsewhere. (See "Overview of themanagement of chronic kidney disease in children", section on 'Slowing chronic kidney disease progression'.)

    The timing of administration of antihypertensive therapy (ie, morning versus evening dosing) in patients with CKD ispresented elsewhere. (See "Overview of hypertension in acute and chronic kidney disease", section on 'Possiblebenefit from nocturnal therapy'.)

    IMPORTANCE OF PROTEINURIA AND BLOOD PRESSURE CONTROL Multiple studies in animals andhumans have shown that progression of a variety of chronic kidney diseases may be largely due to secondaryhemodynamic and metabolic factors, rather than the activity of the underlying disorder. The major histologicmanifestations of these secondary causes of renal injury are interstitial fibrosis and focal segmentalglomerulosclerosis (called secondary FSGS), which are superimposed upon any primary renal injury that may bepresent. (See "Epidemiology, classification, and pathogenesis of focal segmental glomerulosclerosis", section on'Nephron loss'.)

    Glomerular damage and proteinuria typically occur with progressive chronic kidney disease (CKD), even in primarytubulointerstitial diseases such as chronic pyelonephritis due to reflux nephropathy. Conversely, interstitial fibrosisoccurs with progressive CKD, even in the setting of primary glomerular disease.

    Identification of the factors responsible for secondary injury, such as intraglomerular hypertension, glomerularhypertrophy, and proteinuria greater than 500 to 1000 mg/day, is clinically important because they can be treated,slowing disease progression in many patients. (See "Secondary factors and progression of chronic kidney disease".)

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  • Studies of antihypertensive therapy in proteinuric nondiabetic CKD have focused on two areas: short-term reductionin protein excretion; and long-term protection against progressive kidney disease. Data are limited on nonproteinuricCKD, defined as CKD associated with urine protein excretion less than 500 to 1000 mg/day. Among patients withproteinuric CKD, the preferred agents are drugs that block the renin-angiotensin system, such as angiotensin-converting enzyme inhibitors and, at least in patients with type 2 diabetes, angiotensin II receptor blockers [2,4,5].

    Importance of proteinuria and the proteinuric response In patients with CKD, higher degrees of urinaryprotein excretion are associated with a more rapid decline in glomerular filtration rate (GFR), regardless of theprimary cause of the renal disease and the initial GFR (figure 1). In addition to the initial urinary protein excretion, anumber of studies have reported correlations between reduction in proteinuria with antihypertensive therapy andslower progression of the renal disease. (See 'The proteinuric response as a predictor of outcome' below.)

    Importance of blood pressure control Observational studies show that patients with CKD and a normal bloodpressure have better preservation of glomerular filtration rate (GFR) than hypertensive patients [6]. Interventionalstudies show that lower blood pressure targets (below 130/80 mmHg) are associated with better renal outcomes inpatients with proteinuric CKD (defined as urine protein excretion greater than 500 to 1000 mg/day) [7]. (See 'Effect ofgoal blood pressure on progression of CKD' below.)

    EFFECT OF ANTIHYPERTENSIVE DRUGS ON PROTEINURIA The effect of antihypertensive drugs onproteinuria varies with drug class. When the blood pressure is controlled, renin-angiotensin system (RAS) inhibitorssuch as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are moreeffective than other antihypertensive drugs in reducing proteinuria and in slowing the rate progression of proteinuricchronic kidney disease (CKD), regardless of etiology [3]. These benefits can be demonstrated even in patients whoare not hypertensive and in those with diabetic nephropathy. (See 'Effect of renin-angiotensin system inhibitors onprogression of CKD' below and "Treatment of diabetic nephropathy".)

    The generally greater antiproteinuric effect seen with the ACE inhibitors and ARBs is compatible with a greater fall inintraglomerular pressure, which has been demonstrated in animal models of proteinuric CKD [8,9]. This effect ismediated in part by dilation of both efferent and afferent glomerular arterioles, rather than only the afferent arteriolesas occurs with other classes of antihypertensive drugs. (See "Antihypertensive therapy and progression of chronickidney disease: Experimental studies".)

    Renin-angiotensin system inhibitors A number of trials have identified a preferential benefit of renin-angiotensin system (RAS) inhibitors in reducing proteinuria, compared with other antihypertensive drugs. Therationale behind these studies is the observation that protein excretion varies directly with the intraglomerularpressure in animals with structural glomerular disease [10].

    In addition to the reduction in intraglomerular pressure, a variety of other mechanisms may contribute to RASinhibitor-induced reductions in proteinuria. These include:

    Direct improvement in the permselective properties of the glomerulus by ACE inhibitors, independent ofchanges in glomerular hemodynamics [11,12]. The following findings support this hypothesis:

    Protein excretion progressively declines over weeks to several months, whereas the hemodynamic effectsof ACE inhibition occur rapidly and are then stable [13].

    Acute administration of angiotensin II does not reverse the antiproteinuric effect, despite inducing renaland systemic vasoconstriction, and increasing intraglomerular pressure [14].

    In transgenic rats, overexpression of the angiotensin II receptor (type 1) in glomerular podocytes results insignificant proteinuria, foot process effacement, and glomerulosclerosis [15].

    Angiotensin II reduces the expression of nephrin, a major component of the podocyte slit pore membraneand an important contributor to the glomerular filtration barrier [16]. In contrast, nephrin expression isincreased by ACE inhibitor therapy [17].

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  • ACE inhibitors and ARBs have important side effects in patients with CKD, including the potential to inducehyperkalemia. The risk is low if the glomerular filtration rate is greater than 40 mL/min per 1.73 m and the initialserum potassium is in the low-normal range, and even lower if a diuretic is also given [18]. They can also acutelyreduce the glomerular filtration rate, particularly if the patient is hypovolemic. (See "Major side effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers".)

    ACE inhibitors ACE inhibitors generally reduce protein excretion by about 30 to 35 percent in patients withnondiabetic or diabetic CKD [19-23]. The antiproteinuric effect is most prominent in patients who are on alow-sodium diet or who are treated with diuretics since relative volume depletion results in greater angiotensin IIdependence of the glomerular microcirculation [21,24]. (See 'Importance of salt intake' below.)

    It is unclear whether the ACE inhibitor dose associated with a maximal antihypertensive effect is the same as thatrequired for an optimal antiproteinuric effect. This issue was addressed in a study of 23 proteinuric patients withnondiabetic renal disease who were given increasing doses of spirapril for maximal antihypertensive effect (mediandose of 6 mg/day), as assessed by ambulatory blood pressure monitoring [25]. This dose reduced proteinuria from amean of 2.56 to 1.73 g/day. An additional increase of spirapril to a supramaximal dose (median dose of 12 mg/day)failed to further decrease either blood pressure or proteinuria. In contrast to these findings, other studies havereported a dissociation between the doses required for optimal antihypertensive and antiproteinuric effects,suggesting that the amounts necessary for these two benefits are likely to vary among patients [26].

    Angiotensin II receptor blockers The antiproteinuric effect of angiotensin II receptor blockers (ARBs) hasbeen demonstrated in patients with diabetic and nondiabetic CKD. Their effect on slowing progression of GFRdecline was best demonstrated in diabetic renal disease. It seems likely that they will have a similar renoprotectiveeffect as ACE inhibitors in nondiabetic CKD but supportive data are limited [27]. (See "Treatment of diabeticnephropathy".)

    Studies in humans have found that ARBs are as effective as ACE inhibitors in reducing protein excretion in patientswith CKD [19,28-30]. In a 2008 meta-analysis of 49 randomized trials (mostly small), the reduction in proteinuria at 5to 12 months was similar with ARBs and ACE inhibitors (ratio of means 1.08, 95% CI 0.96-1.22) [19].

    As with ACE inhibition, there appears to be a dose effect, with greater reduction of proteinuria at higher (evensupramaximal) doses in both nondiabetic and diabetic patients [31-34]. In the SMART trial, for example, 269 patientswith proteinuria greater than 1 g/day despite seven weeks of the maximum approved dose of candesartan (16mg/day) were randomly assigned to candesartan at a dose of 16, 64, or 128 mg/day [34]. Patients who received 128mg/day had a significantly greater reduction in proteinuria at 30 weeks compared with those who received 16mg/day (mean difference 33 percent). The blood pressure was not different between groups. Although hyperkalemiarequired the withdrawal of 11 patients from the trial, there was no difference in the incidence of hyperkalemiabetween groups. Further studies of the efficacy and safety are required before such high-dose therapy can berecommended.

    ACE inhibitor plus ARB The reduction in proteinuria appears to be greater when ACE inhibitors are used incombination with ARBs than with either drug alone, although no study has compared combination therapy withdoubling the dose of a single agent [19]. However, it has not been proven that combination therapy improves renaloutcomes and adverse effects may be more common. (See 'Combination of ACE inhibitors and ARBs' below.)

    Other antihypertensive drugs Other antihypertensive drugs have a variable effect on protein excretion. Thesedrugs may be used in addition to RAS-inhibitors to further reduce protein excretion but only one trial (AASK) has

    ACE inhibitors have an antifibrotic effect, which could contribute to the slowing of renal disease progression.(See "Secondary factors and progression of chronic kidney disease", section on 'Tubulointerstitial fibrosis'.)

    The fall in protein excretion induced by RAS inhibitors (and some other antihypertensive drugs describedbelow) may be associated with a reduction in serum lipid levels, which may reduce both the risk of systemicatherosclerosis and the rate of renal disease progression. (See "Secondary factors and progression of chronickidney disease".)

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  • evaluated the efficacy of such regimens on the rate of disease progression in patients with nondiabetic CKD. (See'AASK trial of antihypertensive therapy' below.)

    Calcium channel blockers The non-dihydropyridine calcium channel blockers, such as diltiazem andverapamil, have significant antiproteinuric effects in patients with proteinuria [20,35,36]. By comparison, thedihydropyridines, such as amlodipine and nifedipine, have a variable effect on proteinuria, ranging from an increaseto no effect to a fall in protein excretion [19,35,37].

    Differences between non-dihydropyridine and dihydropyridine calcium channel blockers were illustrated in asystematic review of 23 studies that adjusted for sample size, study length, and baseline values [35]. Based upon ananalysis of monotherapy in 510 patients, non-dihydropyridines decreased mean proteinuria by 30 percent anddihydropyridines increased proteinuria by 2 percent (95% CI 10-54% for the differences between the two drugclasses). Similar observations were noted when these agents were used in combination with ACE inhibitors orARBs: despite similar reductions in blood pressure, the mean change in proteinuria was minus 39 and plus 2 percentfor non-dihydropyridines and dihydropyridines, respectively.

    The mechanisms underlying this varied effect on proteinuria may include preferential afferent arteriolar dilatation withdihydropyridines, which allows more of the aortic pressure to be transmitted to the glomerulus, and differentialabilities of the non-dihydropyridine and dihydropyridine calcium channel blockers to alter renal autoregulation, thepermeability of the glomerulus, and perhaps other factors [35].

    Mineralocorticoid receptor antagonists Mineralocorticoid receptor antagonists (spironolactone studied moreoften than eplerenone) further reduce protein excretion when added to an ACE inhibitor and/or ARB [38-42]. Thefollowing are findings from a meta-analysis that included seven trials in which patients were treated with an ACEinhibitor and/or ARB plus either spironolactone (usually 25 mg/day) or placebo [38]:

    However, most of these studies did not first maximize the dose of the ACE inhibitor or ARB, and themineralocorticoid receptor antagonist was associated with an increased risk of hyperkalemia (relative risk 3.1 in themeta-analysis) [38]. Long-term trials are required to determine whether mineralocorticoid receptor antagonists slowthe rate of progression of the renal disease.

    Direct renin inhibitors (DRI) Direct renin inhibitors, like mineralocorticoid receptor antagonists, further reduceproteinuria when added to an ACE inhibitor or ARB. However, this does not appear to translate into clinical benefit.These issues are discussed in detail elsewhere. (See "Renin-angiotensin system inhibition in the treatment ofhypertension", section on 'Direct renin inhibitors'.)

    Drugs with little or no effect Other antihypertensive drugs have little or no effect on protein excretion[20,22,23]. As an example, beta blockers, diuretics, and the alpha-1-blockers (such as prazosin) typically have alesser antiproteinuric effect than RAS inhibitors [20,22,23]. In a 1995 meta-analysis, ACE inhibitors lowered proteinexcretion by 40 percent compared with 16 percent for beta blockers and 14 percent for other, non-calcium channelblocker antihypertensive drugs [20]. Sympathetic blockers, such as methyldopa and guanfacine, had little effect onprotein excretion.

    Importance of salt intake In patients with proteinuric CKD, the antiproteinuric effect of RAS inhibitors andnon-dihydropyridine calcium channel blockers is impaired with a high salt intake, even when blood pressure controlseems appropriate, and is enhanced with salt restriction [21,43-50]. In addition, the benefits of RAS inhibitors onprevention of end-stage renal disease (ESRD) in patients with proteinuric CKD may be enhanced by a low-salt diet

    There was a significantly greater reduction in proteinuria in the spironolactone group (weighted mean difference800 mg/day, 95% CI 330-1270 mg/day).

    The patients treated with spironolactone also had a modestly but significantly lower systolic pressure (3.4mmHg).

    Short-term changes in estimated GFR (less than one year of follow-up) were similar with spironolactone andplacebo.

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  • and/or mitigated by a high-salt diet [48-50]. Similar findings are seen in diabetic nephropathy. (See "Treatment ofdiabetic nephropathy", section on 'Salt intake and proteinuria'.)

    The following examples illustrate the range of findings:

    Thus, patients treated with ACE inhibitors or ARBs who do not have a sufficient reduction in protein excretiondespite reaching goal blood pressure should be instructed to follow a low-salt diet. An assessment of baselinesodium intake can be achieved by obtaining a 24-hour urine collection for sodium and creatinine (creatinineexcretion is used to assess the completeness of the collection; the expected normal values are discussedelsewhere). If, after several months, the reduction in protein excretion is less than desired, the 24-hour urinecollection can be repeated to determine whether a low-salt diet has been attained. (See "Assessment of kidneyfunction", section on 'Creatinine clearance'.)

    If a low-salt diet is not achieved, administration of a diuretic can enhance the antiproteinuric effect of RAS inhibitors[51,52]. Among patients treated with an ACE inhibitor or ARB, the combination of salt restriction and a diuretic mayprovide a greater antiproteinuric effect and more blood pressure reduction than either intervention alone [53].

    The effects of salt intake and salt restriction on blood pressure and the efficacy of antihypertensive medications arediscussed separately. (See "Salt intake, salt restriction, and primary (essential) hypertension", section on 'Effects ofdietary sodium restriction on blood pressure'.)

    EFFECT OF RENIN-ANGIOTENSIN SYSTEM INHIBITORS ON PROGRESSION OF CKD Clinical trials havedemonstrated a benefit of antihypertensive therapy with renin-angiotensin system (RAS) inhibitors, mostlyangiotensin-converting enzyme (ACE) inhibitors, in patients with proteinuric nondiabetic chronic kidney disease(CKD). The renoprotective effect of angiotensin II receptor blockers (ARBs) has been best demonstrated in patientswith diabetic nephropathy. It seems likely that they have a similar renoprotective effect as ACE inhibitors in

    A crossover trial (HONEST) included 52 patients with proteinuric CKD (mean protein excretion 1.6 g/day, meancreatinine clearance 70 mL/min), all of whom were treated with lisinopril [43]. Four treatments were given inrandom order, each for six weeks: a low-sodium diet with placebo; a low-sodium diet with valsartan; a regular-sodium diet with placebo; and a regular-sodium diet with valsartan. Compared with a regular-sodium diet(mean urinary sodium excretion 184 meq/day), a low-sodium diet (mean 106 meq/day) decreased mean dailyprotein excretion to a significantly greater degree than the addition of valsartan (51 versus 21 percent). Additionof valsartan produced a minimal additional reduction in protein excretion beyond a low-sodium diet.

    A similar difference was noted with blood pressure control. A low-sodium diet reduced the mean systolicpressure from 134 at baseline to 123 mmHg, while the addition of valsartan to either a regular or low-sodiumdiet reduced blood pressure by only 2 to 3 mmHg.

    A high-sodium diet was associated with both a blunting of the proteinuria reduction induced by the ACEinhibitor ramipril and a higher incidence of end-stage renal disease (ESRD) in 500 proteinuric CKD patientsenrolled in the REIN and REIN-2 trials [48]. Patients on a high-sodium diet (defined as a 24-hour urinarysodium excretion greater than 250 mmol of sodium [14 grams of salt] per day) had the following adverseoutcomes compared with patients on a low-sodium diet (defined as a 24-hour urinary sodium excretion lessthan 125 mmol of sodium [7 grams of salt] per day):

    A significantly smaller reduction in proteinuria in response to ramipril therapy at three months (20 versus31 percent). In patients on a lower-sodium diet, this initial three-month reduction in proteinuria persistedover the entire four-year study period. However, the initial reduction in proteinuria waned in patients on ahigh-sodium diet, and returned to pre-ramipril levels by the end of the study.

    A significantly higher incidence of ESRD (32 versus 16 percent). This higher risk of ESRD with ahigh-sodium diet was independent of age, sex, cause of renal disease, and blood pressure. However, theassociation was attenuated after controlling for changes in proteinuria, suggesting that a high-sodium dietmitigated the beneficial effects of the ACE inhibitor.

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  • nondiabetic CKD but supportive data are limited [27]. (See "Treatment of diabetic nephropathy", section on 'Renalprotection with ARBs'.)

    This section will review the trials, and meta-analyses of such trials, that evaluated the efficacy of RAS inhibitorscompared with other antihypertensive drugs on the progression of nondiabetic CKD. The trials that evaluated theimportance of goal blood pressure in such patients are discussed below. (See 'Effect of goal blood pressure onprogression of CKD' below.)

    Meta-analyses Meta-analyses of randomized trials, including those trials presented below, provide evidence insupport of a preferential benefit with ACE inhibitors in proteinuric patients [7,54-59]. In a representativemeta-analysis, patient-level data were analyzed from 11 randomized, controlled trials that enrolled 1860 nondiabeticpatients with CKD; the alternative treatments were other antihypertensive drugs and placebo [55]. After statisticaladjustments, ACE inhibitor therapy compared with the alternative treatments was associated with significantreductions in the rate of progression to end-stage renal disease (ESRD) (7.4 versus 11.6 percent, relative risk 0.69,95% CI 0.51-0.94), while that for doubling of the baseline serum creatinine concentration or end-stage renal diseasewas 13.2 versus 20.5 percent (relative risk 0.70, 95% CI 0.55-0.88). The benefits of ACE inhibitors increased withincreasing baseline proteinuria and were insignificant in patients with proteinuria below 500 to 1000 mg/day [57].ACE inhibitors were also associated with a significantly larger reduction in blood pressure (4.5 versus 2.3 mmHg),although this may be due to the fact that ACE inhibitors were compared with placebo in five of the trials.

    The benefits of ACE inhibitors and ARBs on CKD progression in proteinuric patients was confirmed in ameta-analysis of 12 trials that included patients with severely increased albuminuria (formerly called"macroalbuminuria") or a combination of severely increased albuminuria and moderately increased albuminuria(formerly called "microalbuminuria") [60]. Compared with other antihypertensive drugs, therapy with ACE inhibitorsresulted in a significantly lower incidence of end-stage renal disease (2.6 versus 3.8 percent; relative risk 0.67, 95%CI 0.54-0.84). ARB therapy also reduced the incidence of ESRD compared with other drugs (14 versus 18 percent;relative risk 0.78, 95% CI 0.66-0.90).

    Additional analyses of these trials from the same research group found that the risk of progression increased withhigher baseline systolic pressures above 120 mmHg and increasing proteinuria above 1000 mg/day [7,57]. There isno evidence of benefit from ACE inhibitors or ARBs, or with systolic pressures below 120 mmHg in patients withproteinuria less than 500 mg/day [57]. Patient outcomes may be worse at systolic pressures below 120 mmHg[61,62]. (See 'Proteinuria goal' below and 'Blood pressure goal' below.)

    Benazepril trial The Benazepril trial included 583 patients with a variety of chronic nondiabetic kidney diseases[63]. The patients were already in reasonable blood pressure control on a variety of different medications and werethen randomly assigned to benazepril or placebo in addition to their usual antihypertensive regimen. At baseline, themean serum creatinine was 2.1 mg/dL (186 micromol/L) and mean protein excretion was 1.8 g/day.

    The following results were noted:

    The mean attained blood pressure during the trial was significantly lower with benazepril than with placebo(135/84 versus 144/88 mmHg).

    Benazepril therapy reduced protein excretion by 25 percent compared with placebo.

    Progression to the primary endpoint (defined as doubling of the serum creatinine concentration or progressionto dialysis) occurred in 31 of 300 patients treated with benazepril versus 57 of 283 in the placebo group. Therelative risk reduction was 53 percent in the entire group, 71 percent in those with a baseline creatinineclearance above 45 mL/min, and 46 percent in those with a baseline creatinine clearance 45 mL/min.

    There was benefit in patients with chronic glomerular diseases and in the few patients with diabeticnephropathy who were enrolled; the findings were inconclusive in hypertensive nephrosclerosis because toofew events occurred. Subsequent trials have shown that ACE inhibitors are associated with a slower rate ofdecline in glomerular filtration rate in proteinuric patients with primary hypertension (formerly called "essential"

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  • REIN trial A benefit was also noted in a report from the Ramipril Efficacy In Nephropathy (REIN) trial in whichpatients with nondiabetic CKD were randomly assigned to ramipril or placebo plus other antihypertensive therapy toattain a diastolic pressure below 90 mmHg [64]. At baseline, the mean serum creatinine was 2.4 mg/dL (212micromol/L) and mean protein excretion was 5.3 g/day.

    The degree of blood pressure control was the same in both groups. The trial was terminated prematurely in patientsexcreting more than 3 grams of protein per day because of a significant benefit with ACE inhibition in amelioratingthe rate of decline of renal function (0.53 versus 0.88 mL/min per month for placebo).

    Whether these benefits with ramipril continued over time in patients excreting more than 3 grams of protein per daywas addressed in an observational follow-up study of those initially enrolled in the trial phase [65]. The rate ofdecline of renal function and the need for dialysis were the principal outcomes assessed in patients who continued toreceive ramipril (51 patients) and in those originally randomized to conventional antihypertensive therapy plusplacebo who were switched to ramipril at the beginning of the observational follow-up (46 patients) [65]. At 20months (and at 44 months for the trial phase and observational follow-up combined), the following benefits werenoted:

    Additional follow-up at 60 months found that some patients on continued ramipril therapy even had increased GFRcompared with baseline values [66].

    Post-hoc analyses of the REIN trial evaluated the benefits of ramipril in patients with varying degrees of proteinuriaand reductions in GFR [67,68]:

    Thus, the original and follow-up ramipril studies strongly suggest that patients who particularly benefit are those withprominent proteinuria, a finding similar to that noted in other trials [64-67,69,70]. Significant benefit was also seen in

    hypertension) and in proteinuric blacks with benign hypertensive nephrosclerosis compared with a beta blockeror calcium channel blocker therapy, despite equivalent degrees of blood pressure control. (See 'AASK trial ofantihypertensive therapy' below.)

    Benazepril had no benefit in the 64 patients with polycystic kidney disease or in patients with protein excretionbelow 1000 mg/day, two settings in which hemodynamically-mediated glomerular disease does not appear tobe prominent. (See "Course and treatment of autosomal dominant polycystic kidney disease", section on'Treatment'.)

    The mean rate of decline of the glomerular filtration rate (GFR) decreased from 0.44 to 0.10 mL/min per 1.73m for patients originally randomized to ramipril, and from 0.81 to 0.14 mL/min per 1.73 m for those notoriginally given ramipril.

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    At the end of the observational follow-up, the group originally randomized to ramipril had a significantly higherGFR (35.5 versus 23.8 mL/min per 1.73 m ).

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    During the entire 44 month period of follow-up (including the trial and observational phases), the incidence ofend-stage renal disease was significantly lower in those patients originally assigned to ramipril compared withthose originally assigned to other antihypertensive drugs and then switched to ramipril (19 versus 35 percent).

    The administration of ramipril to patients with a GFR less than 45 mL/min and proteinuria between 1.5 and 3g/day resulted in a significantly lower rate of decline in GFR (-0.31 versus -0.40 mL/min/1.73 m per month forother therapy) and a decreased incidence of end-stage renal disease (18 versus 52 percent) [67].

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    Renal benefits of ramipril were observed whether the initial (baseline) GFR was within the lowest (11 to 33mL/min/1.73 m ), middle (33 to 51 mL/min/1.73 m ), or highest tertile (51 to 101 mL/min/1.73 m ). Comparedwith other drugs, ramipril therapy decreased the rate of GFR decline by 20, 22, and 35 percent, respectively,and the incidence of end-stage renal disease by 33, 37, and 100 percent, respectively [68]. The incidence ofadverse events was similar across the tertiles and within each tertile for the ramipril and other treatmentgroups.

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  • patients with non-nephrotic proteinuria (1.0 to 2.9 g/day) [67].

    Relative benefits from ramipril also appear to be independent of the initial GFR, but absolute benefits are greaterwhen initiated earlier in the course of renal disease. Given that many patients had significant renal insufficiency (eg,the lowest tertile had a GFR between 11 to 33 mL/min/1.73 m ), the low incidence of adverse effects with ramiprilreflects the exclusion of patients with evidence of hypovolemia and renal artery stenosis, as well as thediscontinuation of diuretics prior to initiating ACE inhibitor therapy.

    REIN-2 trial A lack of renoprotection with a dihydropyridine calcium channel blocker, even when used asadd-on therapy to an ACE inhibitor to attain aggressive blood pressure control, was found in the REIN-2 trial ofpatients with nondiabetic proteinuric CKD (mean baseline GFR 35 mL/min and mean proteinuria 2.9 g/day) [71]. Inthis trial, 335 patients receiving ramipril (2.5 to 5 mg/day) were randomly assigned to conventional (diastolicpressure less than 90 mmHg) or intensified (0.22 (this protein-to-creatinine ratiois approximately equivalent to 300 mg protein in 24 hours); the mean protein excretion in this subgroup was 1.5g/day in men and 1.2 g/day in women. In these patients, ramipril led to a significant 36 percent reduction in therate of decline in GFR (2.0 mL/min per year) and a significant 48 percent reduction in the composite endpoint.

    In the remaining patients who had a urine protein-to-creatinine ratio of 0.22 or less, there was no significant

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  • The final results at four years of follow-up showed no difference among the drug groups in reducing the rate ofdecline of GFR. However, the incidence of the composite endpoint was significantly lower in those treated withramipril than with amlodipine (6.9 versus 8.2 percent per year) or metoprolol (6.9 versus 8.7 percent per year) [73].(See "Clinical features, diagnosis, and treatment of hypertensive nephrosclerosis", section on 'Choice ofantihypertensive agent'.)

    After completion of the AASK trial, all of the participants were invited to enroll in a cohort phase during which ramiprilwas prescribed to everyone. After five years of additional follow-up during the cohort phase, progression ofnephropathy was significantly slowed but not stopped [74,75]. Compared with patients with controlled clinic bloodpressure or white coat hypertension (ie, hypertension in the doctor's office but not at home), target organ damage(proteinuria, left ventricular hypertrophy) was more likely in patients with elevated blood pressure at night despitegood blood pressure control in the office, masked hypertension (which refers to patients with normal office bloodpressure who are hypertensive during the day on ambulatory monitoring), isolated ambulatory hypertension, orsustained hypertension [75]. (See "Ambulatory blood pressure monitoring and white coat hypertension in adults",section on 'Nocturnal blood pressure and nondippers' and "Ambulatory blood pressure monitoring and white coathypertension in adults", section on 'Masked hypertension'.)

    Use in advanced disease A question that is often asked is whether the benefit from ACE inhibitors or ARBsextends to patients with advanced CKD, particularly given the increased risk of hyperkalemia. Stated differently, isthere a serum creatinine concentration above which one would not use such therapy? The answer to this questionappears to be no, except for truly end-stage disease.

    The potential value of RAS inhibition in advanced disease was best shown in a Chinese study in which 422 patientswith nondiabetic CKD were randomly assigned to benazepril or placebo plus other antihypertensive therapy to attaina systolic and diastolic pressure below 130 and 80 mmHg, respectively [76]. Based upon the baseline serumcreatinine concentration, patients were divided into two groups:

    All patients had an eight-week run-in period in which they received benazepril at 10 mg/day for four weeks; theywere closely monitored with weekly measurements of serum creatinine and potassium levels and blood pressure;the dose was increased to 10 mg twice daily if the serum creatinine concentration increased less than 30 percent,the serum potassium remained below 5.6 meq/L, and no adverse effects occurred. During this period, 94 patientswere excluded from further study because of dry cough, marked changes in renal function, severe hyperkalemia, orpoor adherence. Thus, the study group was highly selected.

    All 104 remaining patients in group 1 received benazepril (at 10 mg twice daily, since it was deemed unethical toadminister placebo), while the 224 patients remaining in group 2 were randomly assigned to benazepril (10 mg twicedaily) or placebo. Additional antihypertensive therapy was administered to attain blood pressure goals. The primaryendpoint was the composite of doubling of the serum creatinine level, end-stage renal disease (ESRD), or death,while secondary endpoints were change in proteinuria and rate of progression of the renal disease.

    The following results were noted at a mean follow-up of 3.4 years:

    difference in mean decline in GFR or the composite clinical endpoint among the treatment groups.

    Group 1 consisted of 141 patients with a serum creatinine concentration between 1.5 to 3.0 mg/dL (133 to 265micromol/L). The mean estimated glomerular filtration rate (GFR) and level of proteinuria were 37 mL/min per1.73 m and 1.6 g/day, respectively.

    2

    Group 2 consisted of 281 patients with a serum creatinine concentration between 3.1 to 5.0 mg/dL (274 to 442micromol/L). The mean estimated GFR and proteinuria were approximately 26 mL/min per 1.73 m and 1.6g/day.

    2

    Significantly fewer group 2 patients (mean GFR of 26 mL/min per 1.73 m ) treated with benazepril reached theprimary endpoint (41 versus 60 percent with placebo), resulting in an overall risk reduction of 43 percent withactive therapy. The primary endpoint was reached less often in group 1 patients (22 percent), who had less

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  • The absence of serious hyperkalemia may have resulted from one or more of the following factors: approximately 5percent of patients in group 2 were excluded from the study because of hyperkalemia during the eight-week run-inperiod; dietary intake of potassium was likely to be lower than in Western patients; and diuretics were used in morethan 80 percent of patients, possibly resulting in increased renal potassium excretion [77]. The exclusion of patientswith diabetes, which is associated with an increased risk of hypoaldosteronism, may also have contributed to the lowincidence of hyperkalemia. (See "Etiology, diagnosis, and treatment of hypoaldosteronism (type 4 RTA)", section on'Diabetes and renal insufficiency'.)

    Further evidence in support of benefit from ACE inhibitors in patients with advanced renal failure was found in theREIN trial. As previously mentioned, patients with an initial GFR within the lowest group (11 to 33 mL/min/1.73 m )had a 20 percent decrease in the rate of decline in GFR and a 33 percent reduction in the incidence of end-stagerenal disease [68] (see 'REIN trial' above). In addition, the use of ACE inhibitors or ARBs in patients with veryadvanced disease (serum creatinine concentration greater than 6.0 mg/dL [530 micromol/L]) does not appear tohasten the need for long-term dialysis, although the risk of hyperkalemia is increased [78]. ACE inhibitors alsoappear to slow the rate of loss of residual renal function being treated with peritoneal dialysis [79].

    Use in elderly patients It is not known whether the benefits from renin-angiotensin system (RAS) inhibition inproteinuric CKD extend to patients older than 70 years because most of the above trials did not include suchindividuals [70]. This is an important issue since older patients are more likely to have adverse effects from therapy,including acute kidney injury and hyperkalemia. (See "Major side effects of angiotensin-converting enzyme inhibitorsand angiotensin II receptor blockers", section on 'Reduction in GFR' and "Major side effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers", section on 'Hyperkalemia'.)

    Older patients with CKD are also less likely to have proteinuria, which was required in most of the RAS inhibitiontrials cited above. This was demonstrated in an analysis of 1190 National Health and Nutrition Examination Survey(NHANES) participants who were over age 70 years and had CKD, which was defined as an estimated GFR 200 mg/g of creatinine (approximately 300 mg/day) [70]. Thislevel of proteinuria was present in only 13 percent. There is no evidence of benefit from RAS inhibition in patientswith protein excretion below 500 mg/day [57].

    In addition, older patients are less likely to live long enough to derive the benefits of RAS inhibition. As an example,in a study of 790,342 military veterans aged 70 years or older, the number-needed-to-treat (NNT) with RAS inhibitionto prevent one ESRD event was calculated, assuming that such medications result in a 30 percent lower relative risk(similar to the effect in younger populations) [80]. The NNT ranged from 2500 among patients with an estimatedGFR 45 to 59 mL/min per 1.73 m and no dipstick proteinuria to 16 among those with an estimated GFR 15 to 29mL/min per 1.73 m and 2+ or greater dipstick proteinuria. More than 90 percent of the cohort had a NNT greaterthan 100, comparing unfavorably to the NNT calculated from trials of younger patients (which were usually less than25).

    The findings above suggest that the great majority of patients over age 70 years with CKD would not benefit from

    severe disease and were all treated with benazepril.

    In group 2 patients, benazepril was associated with the following significant benefits: a lower rate of doubling ofthe serum creatinine concentration and of reaching ESRD by 51 and 40 percent, respectively; a greaterreduction of proteinuria (52 versus 20 percent); and a lower rate of decline in GFR (6.8 versus 8.8 mL/min per1.73 m per year).

    2

    The extent of proteinuria reduction in patients with protein excretion above 1 g/day correlated significantly withthe rate of decline in estimated GFR.

    The benefits with benazepril were independent of blood pressure lowering since the attained blood pressureswere comparable in all groups.

    The incidence of major adverse effects was similar with benazepril and placebo.

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  • RAS inhibition for renoprotection and may have harm from a higher rate of side effects [81]. However, thisconclusion does not necessarily apply to patients excreting more than 1 g/day of protein in whom RAS inhibition mayslow disease progression, a benefit that is likely to be greater than any risks. Careful monitoring is warranted. (See'Lack of benefit in nonproteinuric CKD' below.)

    The proteinuric response as a predictor of outcome In nondiabetic CKD, a number of studies, primarilyobservational post-hoc analyses, and meta-analyses, have reported correlations among the initial degree of urinaryprotein excretion, reduction in proteinuria with therapy, and decreased progression of renal disease[7,55,64,67,69,82-87]. As examples:

    In addition to the benefit associated with proteinuria reduction in patients with CKD, the loss of an initialantiproteinuric response to antihypertensive therapy correlates with an exacerbation of renal dysfunction. This wasillustrated in a report of 33 patients with nondiabetic renal disease and an initial antiproteinuric response to ACEinhibition, 14 of whom escaped from this benefit after approximately 19 months [86]. These patients had a significantincrease in the rate of loss of creatinine clearance (+0.05 versus -0.70 mL/min per month during the periods ofresponse and escape, respectively).

    Most studies have found that better renal outcomes are associated with agents that lower both proteinuria and bloodpressure. However, no trials have examined "goal proteinuria" in which different levels of proteinuria reduction werecompared.

    With respect to monitoring proteinuria, we generally monitor protein excretion by repeated measurement of the urineprotein-to-creatinine ratio or albumin-to-creatinine ratio in a random urine specimen. These tests are reasonablyaccurate in detecting changes in protein excretion. (See 'Proteinuria goal' below and "Assessment of urinary proteinexcretion and evaluation of isolated non-nephrotic proteinuria in adults".)

    Adverse effects Renin-angiotensin system (RAS) inhibition can be associated with a variety of adverse effects.(See "Major side effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers".)

    With respect to progression of the renal disease, ACE inhibitors and ARBs can cause a decline in renal function anda rise in serum potassium that typically occur one to two weeks after the onset of therapy. Thus, repeatmeasurement of the serum creatinine and potassium should be obtained during this time frame after the initiation orintensification of therapy.

    The long-term clinical significance of a modest and stable rise in serum creatinine after the initiation or intensificationof RAS inhibitor therapy is uncertain since it is due in part to a reduction in intraglomerular pressure, which is thoughtto contribute to the slowing of disease progression. An initial elevation in serum creatinine of as much as 30 to 35percent above baseline that stabilizes within the first two months of therapy is considered acceptable and not areason to discontinue therapy as long as there is not an excessive fall in blood pressure; the latter is most likely tooccur in patients who are volume depleted at the initiation of therapy due, for example, to diuretic therapy [88,89].Rather than being an adverse effect, a review of 12 randomized trials found that patients with an acute and stablerise in serum creatinine of up to 30 percent were more likely to have long-term preservation of renal function [88].

    Combination of ACE inhibitors and ARBs A number of trials and meta-analyses have demonstrated thatcombination ACE inhibitor/ARB therapy has a greater antiproteinuric effect than either agent alone [19,90-95]. A2013 meta-analysis of 59 trials with 1 to 49 months of follow-up found that combination therapy significantly reducedprotein excretion compared with monotherapy (by almost 400 mg/day) and also increased the likelihood of achieving

    In the MDRD study, for each 1 g/day reduction in protein excretion during the first four months, the rate ofdecline in GFR fell by 0.9 to 1.3 mL/min per year [85]. The fall in proteinuria was related to the blood pressure,being more prominent in those with more aggressive blood pressure control.

    Among patients with protein excretion 3 g/day in the REIN trial, the rate of decline in GFR correlated inversely

    with the degree of proteinuria reduction and the magnitude of benefit seemed to exceed that expected for thedegree of blood pressure lowering [64].

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  • a normal level of albumin excretion (by 9.4 percent) [90]. Lowering of proteinuria has been a marker for betteroutcomes in other studies. (See 'The proteinuric response as a predictor of outcome' above.)

    In addition to lack of proven benefit in proteinuric CKD, combination therapy may have adverse effects asdemonstrated in the ONTARGET trial of 25,620 patients with preexisting vascular disease or diabetes. ONTARGETwas designed to evaluate the effects of ramipril, telmisartan, or the combination of both drugs on cardiovascular andrenal endpoints during approximately 4.5 years of follow-up [96]. A later report from ONTARGET evaluated theeffects of combination therapy versus monotherapy in the subset of 5623 patients who, at baseline, had reducedrenal function (defined as an estimated glomerular filtration rate less than 60 mL/min per 1.73 m ) and/or proteinuria(defined as a urine albuminto-creatinine ratio greater than 177 mg/g for men and 248 mg/g for women, thresholdsthat roughly correlate with more than 300 mg of albumin on a 24-hour urine collection) [97].

    The following observations were made among the patients with reduced renal function:

    Combination therapy with an ACE inhibitor and ARB compared with monotherapy also increases the incidence ofhyperkalemia and hypotension (by 3.4 and 4.6 percent, respectively, in a systematic review of 59 trials) [90]. (See"Major side effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers", section on'Combination of ACE inhibitors and ARBs'.)

    Given the lack of proven benefit and the potential harms demonstrated in various large trials (ie, ONTARGET,ALTITUDE, VA NEPHRON-D), we recommend not using combination therapy with ACE inhibitors and ARBs inpatients with nondiabetic CKD with the possible exception of IgA nephropathy. Similarly, the European Drug Agencystates that combined blockade of the renin-angiotensin system should not be used in any patient. (See 'Proteinuriagoal' below and "Treatment and prognosis of IgA nephropathy", section on 'Proteinuria and blood pressure goals'.)

    Lack of benefit in nonproteinuric CKD The data presented in the preceding section consistently demonstratethe preferential benefits of renin-angiotensin system (RAS) inhibitors in patients with proteinuric chronic kidneydisease (CKD). Thus, when trying to slow the progression of nondiabetic CKD, protein excretion above 1000 mg/dayidentifies patients who are likely to benefit from antihypertensive therapy with RAS inhibitors [7,57,63,67,98].However, some experts would set the threshold at 500 to 1000 mg/day [3,99].

    In contrast, there appears to be no preferential benefit of RAS inhibitors in patients excreting less than 500 mg/day,as occurs in most patients with nephrosclerosis and polycystic kidney disease [57]. (See "Clinical features,diagnosis, and treatment of hypertensive nephrosclerosis", section on 'Choice of antihypertensive agent' and"Hypertension in autosomal dominant polycystic kidney disease", section on 'Choice of agent'.)

    EFFECT OF GOAL BLOOD PRESSURE ON PROGRESSION OF CKD In 2003, the ACE Inhibition inProgressive Renal Disease study group concluded that a systolic pressure below 130 mmHg was associated with alower risk of kidney disease progression in patients with a spot urine total protein-to-creatinine ratio 1000 mg/g

    (which approximately represents protein excretion of greater than 1000 mg/day) [7]. In contrast, there was noevidence of benefit (adjusted relative risk 1.0) in patients with protein excretion less than 1000 mg/day.

    Although these observational data could not exclude the possibility that patients with normal blood pressure or moreeasily controlled hypertension have less severe underlying disease, several trials and meta-analyses have reachedsimilar conclusions. This section will review the trials and meta-analyses that evaluated the importance of goal bloodpressure on the progression of nondiabetic CKD. The trials that evaluated the efficacy of renin-angiotensin system

    2

    Combination therapy resulted in a small but significant increase in the incidence of end-stage renal disease(ESRD, defined as the need for chronic dialysis) or doubling of the serum creatinine (0.79 versus 0.56 percentper year), but a nonsignificant increase in ESRD alone (0.34 versus 0.27 percent per year).

    In the group of patients who had both reduced renal function and proteinuria, combination therapy significantlyincreased the risk of ESRD or doubling of the serum creatinine (4.8 versus 2.8 percent per year), as well asESRD alone (2.7 versus 1.6 percent per year).

    Combination therapy did not reduce the risk of cardiovascular disease or death.

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  • (RAS) inhibitors compared with other antihypertensive drugs on both proteinuria and disease progression arediscussed above. (See 'Effect of antihypertensive drugs on proteinuria' above and 'Effect of renin-angiotensinsystem inhibitors on progression of CKD' above.)

    Meta-analyses Several meta-analyses have synthesized the effects of more aggressive blood pressure loweringon the progression of CKD [100,101]. Overall, more aggressive blood pressure lowering reduces the risk of CKDprogression among patients with proteinuric renal disease, but not among those without proteinuria. Proteinuria wasvariably defined in these studies as a protein-to-creatinine ratio greater than 0.22 g/g or a 24-hour protein excretiongreater than 300 mg:

    MDRD study Results from the multicenter Modification of Diet in Renal Disease (MDRD) trial suggest that boththe rate of progression and the efficacy of antihypertensive therapy are related to baseline protein excretion, which inturn is a reflection of the severity of glomerular injury [98]. Two groups were compared: one with usual bloodpressure control (target mean arterial pressure less than 107 mmHg, which is equivalent to 140/90 mmHg) and onewith more aggressive control (target mean arterial pressure less than 92 mmHg, which is equivalent to 125/75mmHg) over a three-year period. The achieved mean arterial pressures were 96 and 91 mmHg (equivalent to 130/80and 125/75 mmHg, respectively). Almost one-half of the patients were treated with an ACE inhibitor, but its selectiveefficacy was not assessed.

    The results in 585 patients with a mean baseline GFR of 39 mL/min and mean urinary protein excretion of 1.1 g/daycan be summarized as follows (figure 2):

    A subsequent study reported the long-term outcomes of patients enrolled in the initial MDRD study [103]. After thestudy was completed in 1993, all participants were passively followed until 2000 for the incidence of renal failure(defined as dialysis or renal transplantation) and all-cause mortality. The mean difference in blood pressure betweenthe two groups during the trial phase was 7.6/3.8 mmHg; blood pressure was not measured during passivefollow-up. On intention-to-treat analysis, patients in the aggressive control group were significantly less likely to

    One meta-analysis, for example, combined seven goal blood pressure trials including 5,308 patients with CKDthat were followed for at least 1.6 years [100]. Compared with a standard blood pressure lowering, moreaggressive blood pressure control significantly reduced the risk of renal events (defined as end-stage renaldisease [ESRD], a doubling of serum creatinine, or 50 percent reduction in glomerular filtration rate [GFR])among those with proteinuric CKD (38.5 versus 40.5 percent). In contrast, event rates were nonsignificantlyhigher with aggressive blood pressure lowering among patients with nonproteinuric CKD (37.7 versus 35.0percent), although this result was based upon a smaller subgroup.

    A separate systematic review of the three largest of these seven trials (MDRD, AASK, and REIN-2) reached asimilar conclusion [101]. Aggressive blood pressure control was associated with a lower risk of ESRD or deathand a slower rate of decline in glomerular filtration rate in proteinuric patients, but not in patients withoutproteinuria. In addition, aggressive blood pressure control did not reduce the risk of cardiovascular outcomes ordeath in nonproteinuric patients; this issue is discussed elsewhere. (See "Chronic kidney disease and coronaryheart disease", section on 'Blood pressure control'.)

    The loss of GFR was lowest in patients excreting less than 1 g/day (2.8 to 3.0 mL/min year), but no benefit wasseen with aggressive blood pressure control.

    Patients excreting between 1 and 3 g/day had more rapid progression and a modest benefit from aggressiveblood pressure control.

    Patients excreting 3 g/day or more had the fastest rate of progression but a clinically and statistically significantslowing of the rate of progression with aggressive blood pressure control (rate of GFR decline of 10.2 withconventional versus 6.7 mL/min per year with aggressive blood pressure control).

    A secondary analysis suggested that aggressive blood pressure control may be particularly important in blacks[102]. (See "Hypertensive complications in blacks", section on 'Goal blood pressure'.)

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  • experience renal failure (adjusted hazard ratio 0.68, 95% CI 0.57-0.91), or either renal failure or death (0.77, 95% CI0.65-91). Renal failure accounted for approximately 90 percent of events and a hazard ratio was not provided formortality alone.

    However, a subgroup analysis of this extended follow-up revealed that the benefit from aggressive blood pressurecontrol was only significant in patients with protein excretion exceeding 1 g/day (hazard ratio approximately 0.6 to0.7). The hazard ratio was higher and not significant in patients excreting 300 to 1000 mg/day or less than 300mg/day (hazard ratios of 0.8 and >0.9, respectively). When all patients with protein excretion of 1000 mg/day or lesswere combined, there was a significant reduction in the hazard ratio for renal failure (0.79, 95% CI 0.63-0.99) but notfor the composite outcome of renal failure and death.

    A substantial limitation of this report was that blood pressure measurements were not available for either group after1993. As a result, it is unclear whether the correlation between improved outcomes and being originally assigned toa lower target blood pressure is related to the maintenance of lower blood pressures during this period.

    AASK trial of goal blood pressure In the African American Study of Kidney Disease and Hypertension (AASK)trial, 1094 African-Americans with long-standing hypertension, otherwise unexplained slowly progressive CKD, andusually mild proteinuria (median about 100 mg/day) were randomly assigned to one of two blood pressure goals:125/75 or 140/90 mmHg [37]. The attained blood pressures were 128/78 and 141/85 mmHg. At a mean follow-up ofapproximately four years, the mean rate of change in glomerular filtration rate and other renal parameters were notdifferent between the two groups.

    Following completion of the trial phase, participants were invited to continue in a cohort phase of the study, in whichthe blood pressure target for everyone was

  • is associated with an adverse renal prognosis. (See "Treatment and prognosis of IgA nephropathy", section on'Protein excretion above 1 g/day' and "Assessment of urinary protein excretion and evaluation of isolatednon-nephrotic proteinuria in adults".)

    Because of this potential limitation in using only the urine protein-to-creatinine ratio, we suggest the followingapproach to measuring and monitoring protein excretion, which takes into account both the greater accuracy of acomplete 24-hour urine collection and the greater ease of monitoring with a spot urine specimen:

    We suggest a proteinuria goal of less than 1000 mg/day, which is similar to the K/DOQI recommendation of 500 to1000 mg/g creatinine. It may be difficult to attain this goal, particularly in patients with the nephrotic syndrome. Insuch patients, we suggest a minimum reduction in proteinuria of at least 50 to 60 percent from baseline values plusprotein excretion less than 3.5 g/day. This approach is based upon an observational study in 348 patients withmembranous nephropathy and nephrotic syndrome who were treated with renin-angiotensin system (RAS) inhibitionand, in some cases, immunosuppressive therapy and were followed for a minimum of one year [107]. The patientswho attained these goals, when compared with patients who reached only one or neither of these goals, had markedreductions in the rate of loss of glomerular filtration rate (0.17 versus 0.86 mL/min per month) and in the incidence ofend-stage renal disease (ESRD) (9 versus 29 percent, adjusted hazard ratio 0.17). Subnephrotic proteinuria is alsoassociated with a good renal prognosis in primary focal segmental glomerulosclerosis. (See "Treatment of idiopathicmembranous nephropathy", section on 'Importance of attaining remission' and "Treatment of primary focalsegmental glomerulosclerosis", section on 'Degree of proteinuria'.)

    IgA nephropathy represents an exception to the above approach since protein excretion above 1000 mg/day andperhaps above 500 mg/day is associated with a higher risk of disease progression. Thus, the proteinuria goal is lessthan 1000 mg/day and perhaps less than 500 mg/day, if possible, in all patients. The supportive data are presentedelsewhere. (See "Treatment and prognosis of IgA nephropathy", section on 'Protein excretion above 1 g/day' and"Treatment and prognosis of IgA nephropathy", section on 'Proteinuria and blood pressure goals'.)

    BLOOD PRESSURE GOAL

    Blood pressure goals depend upon protein excretion Our approach to goal blood pressure in patients withnondiabetic CKD is as follows:

    These recommendations are similar to those made by the 2012 international KDIGO guidelines for blood pressuremanagement in patients with CKD. They are also consistent with the Eighth Joint National Committee (JNC 8) andCanadian Society of Nephrology guidelines, although these groups did not comment on whether a lower goal should

    A 24-hour urine collection should be obtained during the initial evaluation, measuring the excretion of bothprotein and creatinine. The completeness of the 24-hour urine collection can be estimated from creatinineexcretion. Normal values of creatinine excretion vary with muscle mass and, hence, age, gender, and physicalactivity: in patients under the age of 50 years, 20 to 25 mg/kg estimated lean body weight in men and 15 to 20mg/kg estimated lean body weight in women; and, in patients between the ages of 50 and 90 years, there is aprogressive 50 percent decline in creatinine excretion (to about 10 mg/kg estimated lean body weight in men).(See "Assessment of kidney function", section on 'Creatinine clearance'.)

    If the initial 24-hour urine collection seems complete, then the rate of protein excretion is probably an accurateestimate. The urine protein-to-creatinine ratio on this specimen can be related to the total amount ofproteinuria, and the urine protein-to-creatinine ratio on a random specimen can subsequently be used tomonitor the degree of proteinuria, as long as muscle mass appears stable. If, for example, 24-hour proteinexcretion is 3 g/day in an apparently complete collection and the urine protein-to-creatinine ratio is 2.0, then aratio below 0.7 would represent goal proteinuria below 1 g/day.

    We recommend that blood pressure be lowered to at least less than 140/90 mmHg in all hypertensive patients.

    We recommend that blood pressure be lowered to below 130/80 mmHg, rather than below 140/90 mmHg, inpatients with proteinuric CKD (defined as protein excretion 500 to 1000 mg/day or more).

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  • apply to proteinuric patients [108,109]. Lowering the blood pressure to below 120 mmHg systolic is notrecommended since patient outcomes may be worse [61,62]. Our recommendations for goal blood pressure inpatients with diabetes mellitus, with or without nephropathy, are discussed separately. (See "Treatment ofhypertension in patients with diabetes mellitus", section on 'Goal blood pressure' and "Treatment of diabeticnephropathy".)

    In patients with established atherosclerotic cardiovascular disease, outcomes are better when the systolic pressureis lowered to below 130 to 135 mmHg. The data are presented elsewhere. (See "Blood pressure management inpatients with atherosclerotic cardiovascular disease", section on 'Placebo-controlled trials with a mean baseline BPless than 140/90 mmHg' and "Blood pressure management in patients with atherosclerotic cardiovascular disease",section on 'Goal blood pressure'.)

    Proteinuric patients The best data supporting our recommendations for goal blood pressure in proteinuricpatients with nondiabetic CKD come from the MDRD trial described above, which assessed the efficacy of bothdietary protein restriction and more aggressive blood pressure lowering in patients with CKD. With respect to bloodpressure lowering, the achieved mean arterial pressures in the usual and more aggressive blood pressure controlarms were 96 and 91 mmHg (equivalent to 130/80 and 125/75 mmHg, respectively). This study suggested that, withincreasing degrees of proteinuria at baseline, more aggressive blood pressure lowering provides benefit ascompared with less aggressive blood pressure lowering. As an example, more aggressive lowering was associatedwith slowing of the rate of loss of glomerular filtration rate that was statistically significant only in patients with proteinexcretion of 3 g/day or more at study end (figure 2) [98]. (See 'MDRD study' above.)

    In addition, both patients excreting 3 g/day and those excreting 1 to 3 g/day had, at a mean of 6.2 years, a

    significantly lower rate of both renal failure, defined as dialysis or renal transplantation, and the combined endpointof renal failure or all-cause mortality [103]. However, it was not clear that this difference was due to the lower targetpressure since blood pressure measurements over this period were not available for either group. Nevertheless,these findings are consistent with the meta-analysis cited above, showing benefit from systolic blood pressurelowering to levels below 130 mmHg among CKD patients with protein excretion of 500 to 1000 mg/day or higher.

    Nonproteinuric patients In patients with nonproteinuric (less than 500 to 1000 mg/day) nondiabetic CKD,there is no evidence of renal benefit from lowering the blood pressure below the usual goal of less than 140/90mmHg. (See 'Effect of goal blood pressure on progression of CKD' above.)

    However, in patients with established atherosclerotic cardiovascular disease, outcomes are better when the systolicpressure is lowered to below 130 to 135 mmHg. (See "Blood pressure management in patients with atheroscleroticcardiovascular disease", section on 'Placebo-controlled trials with a mean baseline BP less than 140/90 mmHg' and"Blood pressure management in patients with atherosclerotic cardiovascular disease", section on 'Goal bloodpressure'.)

    INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5 to 6 gradereading level, and they answer the four or five key questions a patient might have about a given condition. Thesearticles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond theBasics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable withsome medical jargon.

    Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail thesetopics to your patients. (You can also locate patient education articles on a variety of subjects by searching on"patient info" and the keyword(s) of interest.)

    SUMMARY AND RECOMMENDATIONS

    th th

    th th

    Basics topic (see "Patient information: Medicines for chronic kidney disease (The Basics)")

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  • Background

    In patients with chronic kidney disease (CKD), higher degrees of urinary protein excretion are associated with amore rapid decline in glomerular filtration rate (GFR), regardless of the primary cause of the renal disease andthe initial GFR (figure 1). Observational studies show that patients with CKD and a diastolic pressure below 90mmHg have better preservation of glomerular filtration rate (GFR) than hypertensive patients. Lower bloodpressure targets (below 130/80 mmHg) are associated with better renal outcomes in patients with proteinuricCKD (defined as urine protein excretion greater than 500 to 1000 mg/day). (See 'Importance of proteinuria andthe proteinuric response' above and 'Importance of blood pressure control' above.)

    The effect of antihypertensive drugs on proteinuria varies with drug class and salt intake:

    When the blood pressure is controlled, renin-angiotensin system (RAS) inhibitors such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are more effective thanother antihypertensive drugs in reducing proteinuria, regardless of the etiology of CKD. This preferentialeffect is thought to be due to a reduction in intraglomerular pressure and perhaps other factors. Theantiproteinuric effects of ACE inhibitors and ARBs appear to be similar. (See 'Renin-angiotensin systeminhibitors' above.)

    The non-dihydropyridine calcium channel blockers diltiazem and verapamil have significant antiproteinuriceffects in patients with proteinuria. By comparison, the dihydropyridines, such as amlodipine andnifedipine, have a variable effect on proteinuria, ranging from an increase to no effect to a fall in proteinexcretion. (See 'Calcium channel blockers' above.)

    Mineralocorticoid receptor antagonists (spironolactone studied more often than eplerenone) furtherreduce protein excretion when added to an ACE inhibitor and/or ARB. (See 'Mineralocorticoid receptorantagonists' above.)

    Other antihypertensive drugs have little or no effect on protein excretion. (See 'Drugs with little or noeffect' above.)

    In patients with proteinuric CKD, the antiproteinuric effect of RAS inhibitors and non-dihydropyridinecalcium channel blockers is impaired with a high salt intake, even when blood pressure control seemsappropriate, and is enhanced with salt restriction. Similar findings are seen in diabetic nephropathy. If alow-salt diet is not achieved, administration of a diuretic can also enhance the antiproteinuric effect ofRAS inhibitors. (See 'Importance of salt intake' above.)

    Multiple randomized clinical trials in patients with nondiabetic CKD, some with placebo control and some withan active control, have demonstrated a benefit of antihypertensive therapy with RAS inhibitors, mostlyangiotensin-converting enzyme (ACE) inhibitors, in patients with proteinuric nondiabetic CKD. It seems likelythat angiotensin receptor blockers have a similar renoprotective effect as ACE inhibitors in nondiabetic CKD butsupportive data are limited. Additional evidence in support of a preferential benefit with ACE inhibitors inproteinuric patients has come from meta-analyses. (See 'Effect of renin-angiotensin system inhibitors onprogression of CKD' above.)

    Post-hoc analyses of these and other studies have shown correlations between the reduction in proteinuriawith therapy and slower progression of renal disease. (See 'The proteinuric response as a predictor ofoutcome' above.)

    When trying to slow the progression of nondiabetic CKD, protein excretion above 500 to 1000 mg/day identifiespatients who are most likely to benefit from antihypertensive therapy with RAS inhibitors. In contrast, thereappears to be no preferential benefit of RAS inhibitors in patients excreting less than 500 mg/day. (See 'Lack ofbenefit in nonproteinuric CKD' above.)

    The three major trials in adults that evaluated the effect of goal blood pressure on CKD progression suggestthat the renal benefit of more aggressive blood control is primarily restricted to patients with higher rates of

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  • Management

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    protein excretion (figure 2). Meta-analyses of randomized trials support this conclusion. (See 'Effect of goalblood pressure on progression of CKD' above.)

    In patients with proteinuric (defined as protein excretion above 500 to 1000 mg/day) nondiabetic CKD, werecommend a renin-angiotensin system (RAS) inhibitor as first-line therapy for the treatment of hypertension(Grade 1A). (See 'Effect of renin-angiotensin system inhibitors on progression of CKD' above.)

    In hypertensive patients with nonproteinuric nondiabetic CKD who have edema, we suggest initiation of adiuretic as first-line therapy (Grade 2C). If there is no edema, we suggest RAS inhibitors as first line therapy(Grade 2C). (See "Overview of hypertension in acute and chronic kidney disease", section on 'Sequence ofantihypertensive therapy in nonproteinuric CKD'.)

    In patients with proteinuric nondiabetic CKD, we suggest a proteinuria goal of less than 1000 mg/day (Grade2C). In patients who are initially nephrotic and in whom this goal is unobtainable, we attempt to achieve aminimum reduction in proteinuria of at least 50 to 60 percent from baseline values plus protein excretion lessthan 3.5 g/day. (See 'Proteinuria goal' above.)

    Because of potential limitations in using only the urine protein-to-creatinine ratio to follow protein excretion, weobtain a 24-hour urine for protein and creatinine excretion during the initial evaluation, and then compare theprotein-to-creatinine ratio to the 24-hour protein excretion. This allows the subsequent use of spot urineprotein-to-creatinine ratios to more accurately estimate the degree of proteinuria. (See 'Proteinuria goal'above.)

    In patients with proteinuric nondiabetic CKD, we recommend a blood pressure goal of less than 130/80 mmHgrather than 140/90 mmHg (Grade 1B). (See 'Effect of goal blood pressure on progression of CKD' above.)

    In patients with nonproteinuric nondiabetic CKD, we recommend a blood pressure goal of at least less than140/90 mmHg (Grade 1B).

    In patients with established atherosclerotic cardiovascular disease, outcomes are better when the systolicpressure is lowered to below 130 to 135 mmHg. The data are presented elsewhere. (See "Blood pressuremanagement in patients with atherosclerotic cardiovascular disease", section on 'Placebo-controlled trials witha mean baseline BP less than 140/90 mmHg' and "Blood pressure management in patients with atheroscleroticcardiovascular disease", section on 'Goal blood pressure'.)

    In most patients with nondiabetic CKD, we recommend not using combination therapy with ACE inhibitors andARBs (Grade 1B). The potential use of this combination in patients with IgA nephropathy is discussedseparately. (See 'Combination of ACE inhibitors and ARBs' above and "Major side effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers", section on 'Combination of ACE inhibitorsand ARBs' and "Treatment and prognosis of IgA nephropathy", section on 'Combination of ACE inhibitor andARB'.)

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