Control of hypertension is the single most important intervention to delay progression of chronic kidney disease (CKD). Extracellular fluid volume expansion is one of the most important factors leading to persistent hypertension in patients with CKD. Older individuals and black patients are more likely to be salt-sensitive and exhibit an antihypertensive response to sodium restriction or diuretic therapy.
If hypertension and proteinuria persist despite sodium restriction, the addition of a diuretic may be beneficial. Thiazide diuretics, if not used as a first-choice antihypertensive drug, are almost always indicated as an additional drug in patients with incompletely controlled hypertension, because these agents augment most other agents used as monotherapy.
Most hypertensive patients will require more than one antihypertensive drug to lower BP below target levels. The combination of diuretics with renin-angiotensin system (RAS) antagonists offers several advantages to include additive BP-lowering efficacy and enhanced reductions in urinary protein excretion. Thiazide diuretics are associated with metabolic complications that are particularly evident when used in high doses. When used in combination with RAS blockade, metabolic complications such as hypokalemia are minimized. The avoidance of hypokalemia has been linked to less thiazide-induced glucose intolerance. Patient persistence on therapy is dependent on well tolerated drug combinations.
Ardavan Mashhadian D.O.
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