How is blood pressure managed in chronic glomerulonephritis?

Updated: Feb 24, 2020
  • Author: Moro O Salifu, MD, MPH, FACP; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Answer

The target blood pressure for patients with proteinuria in excess of 1 g/day is less than 125/75 mm Hg; for patients with proteinuria of less than 1 g/day, the target pressure is less than 130/80 mm Hg.

Angiotensin-converting enzyme inhibitors (ACEIs) are commonly used and are usually the first choice for treatment of hypertension in patients with chronic kidney disease (CKD). ACEIs are renoprotective agents that have additional benefits beyond lowering pressure. They effectively reduce proteinuria, in part by reducing the efferent arteriolar vascular tone, thereby decreasing intraglomerular hypertension.

In particular, ACEIs have been shown to be superior to conventional therapy in slowing the decline of the glomerular filtration rate (GFR) in patients with diabetic and nondiabetic proteinuric nephropathies. Therefore, ACEIs should be considered for treatment of even normotensive patients with significant proteinuria. [14]

The role of angiotensin II receptor blockers (ARBs) in renal protection is increasingly being established, and these medications have been found to retard the progression of CKD in patients with diabetic or nondiabetic nephropathy, much as ACEIs do. [15]

A combination of ACEI therapy and ARB therapy has been shown to achieve better pressure control and preservation of renal function than either therapy alone could. Therefore, in patients without hyperkalemia or an acute rise in serum creatinine levels after the use of either therapy, combination therapy should be attempted. [16]

However, in patients with vascular disease or diabetes, combination ACEI and ARB therapy has been associated with increased adverse effects, including hyperkalemia, worsening renal function, and mortality. As such, combination ACEI and ARB therapy should not be used to treat hypertension in these groups of patients with CKD. [17]

Diuretics are often required because of decreased free-water clearance, and high doses may be required to control edema and hypertension when the GFR falls below 25 mL/min. Diuretics are also useful in counteracting the hyperkalemic potential of ACEIs and ARBs. However, they should be used with caution when given together with ACEIs or ARBs because the decline in intraglomerular pressure induced by ACEIs or ARBs may be exacerbated by the volume depletion induced by diuretics, potentially precipitating ARF.

Beta blockers, calcium channel blockers, [18] central alpha2 agonists (eg, clonidine), alpha1 antagonists, and direct vasodilators (eg, minoxidil and nitrates) may be used to achieve the target pressure.


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