Improving Antihypertensive Agent Selection to Promote Nephroprotection

Introduction: Despite improved control rates of hypertension in the United States during the last twenty years, the rate of chronic kidney disease (CKD) and end-stage renal disease (ESRD) has steadily increased for the same time period. Purpose: The purpose for this review is to examine the evidence that the choice of antihypertensive therapy makes a difference in the promotion of nephroprotection. Method: A systematic comprehensive search of the National Library of Medicine utilizing Medline was conducted. Search terms included “antihypertensive therapy chronic kidney disease” and “nephropathy;” search limits were confined to randomized clinical trials. Results: Angiotensin receptor blockers (ARBs) and Angiotensin-converting enzyme inhibitors (ACEIs) are nephroprotective alone, and particularly in combination. Calcium channel blockers (CCBs) can be effective nephroprotective agents when combined with ACEIs and ARBs. Thiazide-type diuretics (TTDs) and beta-blockiers (BB) are not nephroprotective and TTDs may have nephrotoxic properties. Conclusion: Government sponsored guidelines that recommend TTDs as first line antihypertensive agents because of their lower acquisition costs may be contributing to the current epidemic of CKD and ESRD. ACEIs and ARBs are preferred first-line agents because they are effective in the prevention of renal as well as cardiovascular and cerebrovascular target organ damage associated with hypertension. When diuretic therapy is indicated for hypertension control, indapamide is preferred over TTDs for nephroprotection.