Impact of chronic kidney disease and diabetes mellitus on choice of renin angiotensin system-inhibitors in patients with hypertension and heart failure

Abstract

Blood pressure (BP)–lowering is a cornerstone of cardiovascular risk reduction in patients with hypertension and heart failure (HF). Antihypertensive agents recommended by current international guidelines for such individuals include angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), β–blockers and diuretic agents. However, as high proportions of patients with HF suffer simultaneously from other co–morbidities such as chronic kidney disease (CKD) and/or diabetes, selection of the appropriate antihypertensive regimen should take into account the specific indications and contraindications of antihypertensive drugs and combinations in patients with CKD as well as the diverse effects of different antihypertensive drug classes on glucose metabolism. ACEIs and ARBs represent the drugs of first choice for patients with diabetic nephropathy or non-diabetic proteinuric kidney disease, but in patients with non–diabetic CKD without proteinuria they have no specific indication. Furthermore, the ACEI and ARB combination was associated with adverse renal effects in recent clinical trials. With regards to the metabolic effects of antihypertensive drugs, older β–blockers and diuretic agents were shown to deteriorate insulin sensitivity and to elevate the risk of new–onset diabetes, while ACEIs and ARBs have neutral or even beneficial impact on glucose metabolism. This chapter will discuss currently available clinical evidence on the effect of antihypertensive treatment on kidney disease progression and on metabolic profile, aiming to offer insights on the choice of the appropriate BP–lowering regimen in patients with HF in the presence of CKD and/or diabetes.