PHARMACOLOGIC THERAPY

Diabetes and Hypertension With CKD

• Progression of CKD can be limited by optimal control of hyperglycemia and hypertension.
Figure 74–2 provides an algorithm for management of diabetes in CKD.
• For more information on diabetes, see Chap. 19.
• Adequate blood pressure (BP) control (Fig. 74–3) can reduce the rate of decline in
GFR and albuminuria in patients without diabetes. KDIGO guidelines recommend a
target blood pressure of 140/90 mm Hg or less if urine albumin excretion or equivalent
is less than 30 mg/24 h.
• If urine albumin excretion is greater than 30 mg/24 h or equivalent, the target blood
pressure is 130/80 mm Hg or less and initiate first-line therapy with an angiotensinconverting
enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB).
Add a thiazide diuretic in combination with an ARB if additional reduction in
proteinuria is needed. Nondihydropyridine calcium channel blockers are generally
used as second-line antiproteinuric drugs when ACEIs or ARBs are contraindicated
or not tolerated.
• ACEI clearance is reduced in CKD; therefore, treatment should begin with the lowest
possible dose followed by gradual titration to achieve target BP and, secondarily, to
minimize proteinuria. No individual ACEI is superior to another.
• For more information on hypertension, see Chap. 10.