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Which Antihypertensive Agents in Chronic Kidney Disease?
- Andrew S. Levey, MD; and
- Katrin Uhlig, MD, MS
- From Tufts-New England Medical Center, Boston, MA 02111
Hypertension is common in chronic kidney disease and is a risk factor for progressive loss of kidney function and kidney failure, as well as cardiovascular disease (CVD) (1, 2). In this issue, Rahman and colleagues (3) report the outcomes of CVD in a subgroup of patients with chronic kidney disease from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). The outcomes of kidney disease in the same subgroup were previously reported (4). These reports are important because 17% of ALLHAT participants had chronic kidney disease, making it the largest study of hypertension treatment in patients with this disorder. In this editorial, we compare Rahman and colleagues' results with those of previous studies in patients with chronic kidney disease that looked at the efficacy of antihypertensive agents that interrupt the renin–angiotensin system.
Previous Studies of Chronic Kidney Disease
Previous studies of chronic kidney disease included patients with recognized kidney disease and hypertension who were recruited primarily from nephrologists' practices (1). Authors often excluded elderly patients and those with CVD. The studies usually compared an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-receptor blocker (ARB), generally in combination with a diuretic, with other antihypertensive agents or placebo. Treating physicians were allowed to use additional antihypertensive agents in both groups to achieve a blood pressure of less than 140/90 mm Hg. The mean follow-up times ranged from 2 to 4 years. The authors ascertained progression of kidney disease from a composite outcome of doubling of baseline serum creatinine levels (approximately equivalent to a halving of glomerular filtration rate [GFR]) or kidney failure. Most trials showed that the ACE inhibitor– or ARB-based regimens reduced proteinuria, slowed the decrease in GFR, and delayed the onset of kidney failure more than other regimens, even though all comparison groups achieved equivalent levels of blood pressure. Point estimates for …
