Ree ney DMUs ey bs Fsigrnoe asses AGENTS IN CHRONIC KIDNEY DISEASE ji Bass aa yy eres PORT eas ELC) Pressure Target Preferred Agents for CKD, with or without ty Type of Kidney Disease Diabetic Kidney Disease Nondiabetic Kidney ACE inhibitor Diuretic preferred, Disease with Spot Urine or ARB then BB or CCB Total Protein-to-Creatinine Ratio 2200 mg/g Nondiabetic Kidney iureti Disease with Spot Urine ee Total Protein-to-Creatinine ‘ARB, BB or CCB Ratio <200 mg/g i <130/80 None preferred Kidney disease CCB, diuretic, BB, in the Kidney _ diure Transplant Recipient ACE inhibitor, ARB Source: National Kidney Foundation. K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease AM J Kidney Dis 43:S1-S290, 2004 (suppl 1)Algorithm for Evaluation and Management of Hypertension and Use of Antihypertensive Agents in CKD Evaluation of the patient with CKD Does the patient have diabetic kidney disease? OR Does the patient have nondiabetic kidney disease with spot urine total protein-to-creatinine ratio 2200 mg/g? YES Can an ACE inhibitor or ARB be introduced or increased? Is BP <130/80 YES mm Hg? US aro UT ae eC diuretic or other agent Monitor response, PT enti ECC ea eadDIABETIC KIDNEY DISEASE Hypertension and Antihypertensive Agents in Diabetic Kidney Disease Other Agents to Reduce Clinical Assessment Target Blood Pressure Preferred Agents CVD Risk and Reach Target for CKD Blood Pressure Diuretic preferred, then Blood Pressure ACE inhibitor a Y 2130/80nm Hy <130/80mm Hg ane beter acm Blood Pressure ACE inhibitor <130/B0mm Hg or ARB. Letters in green boxes (Jif) denote strength of recommendations. See Appendix.STE CELE EL Tan orto (adapted from Table 110, Guideline 8) + ACE inhibitor or ARB for type 1 and type 2 diabetes with spot urine albumin-to-creatinine ratio 30-300 mg/g (microalbuminuria) + ACE inhibitor preferred for type 1 diabetes with spot urine albumin-to- creatinine ratio >300 mg/g (macroalbuminuria) ACE inhibitor or ARB ARB preferred for type 2 diabetes with spot urine albumin-to-creatinine ratio >300 mg/g (macroalbuminuria) «+ Either agent can be used as an alternative agent, if the preferred agent cannot be used + Use moderate to high doses (Guideline 11) For patients with + Consider a lower systolic BP goal spot urine total + Consider measures to reduce proteinuria in-to-creatini ~ Increase dose of ACE inhibitor or ARB Protein-to-creatinine se AcE inhibitor or ARB in combination ratio >500-1000 mg/g - Add or increase dosage of other agents that lower proteinuria Monitor GER + IF GFR decline is >30% from baseline within 4 weeks, evaluate causes + Continue ACE inhibitor or ARB if GFR decline is <30% from baseline value (Guideline 11) over four monthsClinical Assessment Blood pressure 2130/80 mm Hg and spot urine total protein-to-creatinine ratio 2200 mg/g Blood pressure 2130/80 mm Hg and spot urine total protein-to-creatinine ratio <200 mg/g Blood pressure «130/80 mm Hg and spot urine total protein-to-creatinine ratio 2200 mg/g Blood pressure «130/80 mm Hy and spot urine total protein-to-creatinine ratio <200 mg/g NONDIABETIC KIDNEY DISEASE Target Blood Pressure Preferred Agents ‘for CKD «130/80 mm Hg ‘ACE Inhibitor or ARB «130/80 mm Hy None preferred ACE Inhibitor or ARB None preferred Additional Agents to Reduce CVD Risk and Reach Target Blood Pressure Diuretic preferred, then beta-blocker or calcium- channel blocker Diuretic preferred, then ACE inhibitor, ARB, beta-blocker or calcium-channel blocker Diuretic preferred, then beta-blocker or calcium- channel blocker Letters in green boxes (04) denote strength of recommendations. See Appendix.Summary of Recommendations in Nondiabetic Kidney Disease (adapted from Table 118, Guideline 9) + Dietary sodium intake <2.4 g/d » BMI <25 kg/m? + Exercise and physical activity + Moderation of alcohol intake Diet and other therapeutic lifestyle changes for all patients + Smoking cessation ACE inhibitor or ARB * ACE inhibitor preferred if spot urine total + ARB can be used as alternative agent, if ACE inhibitor : we cannot be used Protein-to-creatinine , yse moderate to high doses (Guideline 11) ratio 2200 mg/g + Consider ACE inhibitor and ARB in combination Diuretic if spot + CKD Stages 1-3: Thiazide, loop, or potassium-sparing urine total protein- (use with caution with ACE inhibitor or ARB) to-creatinine ratio _* CKD Stages 4-5: Loop diuretic <200 mg/g + See Guideline 12 for dosages + For patients treated initially with an ACE inhibitor or ARB = Add diuretic first Systolic BP goal ~ Then add CCB or BB : = Avoid dihydropyridine CCB without an <130 mm Hg ACE inhibitor or ARB + For patients treated initially with diuretics ~ Add ACE inhibitor, ARB, CCB or BB For patients with + Consider a lower systolic BP goal spot urine total + Consider measures to reduce proteinuria : «Increase dose of ACE inhibitor or ARB Protein-to-creatinine se Ace inhibitor or ARB in combination ratio >500-1000 mg/g - ‘Add or increase dosage of other agents that lower proteinuria + ACE inhibitors and ARBs may cause hyperkalemia ~ Avoid other medications that cause hyperkalemia, if possible (potassium supplements, NSAIDs, Cox 2 inhibitors, potassium- Monitor serum sparing diuretics) j - Evaluate causes of hyperkalemia potassium = Treat hyperkalemia with diuretics (Guidelines 11-12) - Continue ACE inhibitor or ARB if serum potassium <5.5 mEq/L + Diuretics may cause hypokalemia - Evaluate causes of hypokalemia = Treat hypokalemia with caution in CKD . + If GFR declines >30% from baseline within 4 weeks, Monitor GFR evaluate causes (Guidelines 11-12) + Continue ACE inhibitor, ARB or diuretic if GFR decline is <30% from baseline value over four monthsKIDNEY TRANSPLANT RECIPIENTS ‘Additional Agents to Gina AsesmetTagt tod Pasar PeneAetsece Ran eah CCB, diureti Blood Pressure , Slurtics, <130/80 mmHg None preferred ACE inhibitor, 2130/60 mm Hg 5 ARB, beta-blocker Blood Pressure «130/80 mm Hg None preferred Letters in green boxes (if) denote strength of recommendations. See Appendix. Summary of Recommendations in Kidney Transplant Recipients (adapted from Table 122, Guideline 10) + All antihypertensive agents are effective, including CCB, diuretic, ACE inhibitor, ARB, and BB Systolic BP goal + Dihydropyridine CCBs are associated <130 mm Hg with higher levels of GFR during the first 1-2 years + Nondihydropyridine CCBs may raise levels of cyclosporine, tacrolimus and sirolimus Monitor GFR ACE inhibitor, ARB or diuretic may cause acute (Guidelines 11 decline in GFRACE INHIBITORS AND ARBs IN CKD Summary of Use of ACE Inhibitors and ARBs in CKD (adapted from Table 144, Guideline 11) + Diabetic kidney disease + Nondiabetic kidney disease with spot urine total protein-to-creatinine ratio Indications >200 mg/g + Consider in kidney transplant recipients with spot urine total protein-to-creatinine ratio >500-1,000 mg/g + Hypotension, early decrease in GFR, hyperkalemia, cough, angioneurotic Side-Effects edema, rash, contraindicated in 2nd and 3rd trimesters of pregnancy (recommend contraception to women of child-bearing age) Causes of Early + Extracellular fluid (ECF) volume depletion, hypotension, renal artery disease Decrease in GFR (bilateral or unilateral with a solitary kidney) + Increased potassium intake (high potassium foods, supplements, herbal supplements, transfusions, salt substitutes) + Metabolic acidosis Causes of + Acute GFR decline Hyperkalemia + Drugs (BBs, NSAID, Cox 2 inhibitors, heparin, digoxin overdose, potassium supplements, herbal supplements, potassium-sparing diuretics, cyclosporine, tacrolimus, pentamidine, trimethoprim, lithium) + Laboratory error Frequency of ‘ 2 : aa 7, + If SBP <120 mm Hg, GFR <60 mL/min/1.73 m2, change in GFR 215%, or serum Monitoring for Side potassium >4.5 mEq/L, Effects (BP, GFR, - 4.5 mEq/L for potassium-sparing diuretics + GFR decline >30% within 4 months without explanationVdd ati) eMC Bere M eee CCT) Diagnosis and treatment, treatment 290 of comorbid conditions, slowing progression, CVD risk reduction Kidney damage with normal or + GFR eer 60-89 Estimating progression 3 Moderate + GFR 30-59 ean 4 Severe 4 GFR 15-29 fence ali 5 Kidney failure (ordiaiysis) Replacement (if uremia present) Chronic kidney disease is defined as either kidney damage or GFR <60 mL/min/1.73 m2 for 23 months, Kidney damage is defined as pathologic abnormalities or markers of damave, including abnormalities in blood or urine tests or imaging studies. * Includes actions from preceding stages. Abbreviations: (VD, cardiovascular disease Rating the Strength of Guideline Recommenda’ Grade Recommends Itis strongly recommended that clinicians routinely follow the guideline for eligible patients, There is strong evidence that the practice improves health outcomes. itis recommended that clinicians routinely follow the guideline for eligible patients. There is moderately strong evidence that the practice improves health outcomes. It is recommended that clinicians consider following the guideline for eligible patients. This recommendation is based on either weak evidence or on the opinions of the Work Group and reviewers, that the practice might improve health outcomes. Health outcomes are health-related events, conditions, or symptoms that can be perceived by individuals to have an important effect on their lives. Improving health outcomes implies that benefits outweigh any adverse effects. ane The development of the K/DOQI Clinical oe, Kidney Practice Guidelines on Hypertension and “er Learnir 1g Antihypertensive Agents in Chronic Kidney System Disease was supported by an unrestricted "NATIONAL KIDNEY FOUNDATION educational grant from AstraZeneca Pharmaceuticals. Support for implementation of these guidelines was provided by Merck US Human Health and Bristol-Myers Squibh/Sanofi Pharmaceuticals Partnership. The National Kidney Foundation acknowledges Amgen, founding and principal sponsor of K/DOQI. SP lerdl LS Sel Leal are EL ecole he © 2004 National Kidney Foundation, Inc. eae setter