MKSAP Quiz: Difficult-to-control hypertension
A 62-year-old man is evaluated during a follow-up visit for difficult-to-control hypertension. He also has chronic kidney disease and hyperlipidemia. Following a physical exam and lab studies, what is the most appropriate additional treatment?
A 62-year-old man is evaluated during a follow-up visit for difficult-to-control hypertension. He also has chronic kidney disease and hyperlipidemia. Medications are atorvastatin and carvedilol, as well as maximum doses of lisinopril, amlodipine, and hydralazine.
On physical examination, the average of three blood pressure measurements is 152/98 mm Hg, and pulse rate is 65/min. There is 1+ pitting pretibial lower extremity edema. The remainder of the examination is normal.
Laboratory studies:
| Creatinine | 2.5 mg/dL (221 µmol/L) |
| Potassium | 4.8 mEq/L (4.8 mmol/L) |
| Estimated glomerular filtration rate | 28 mL/min/1.73 m2 |
| Urine albumin-creatinine ratio | 350 mg/g |
Which of the following is the most appropriate additional treatment?
A. Chlorthalidone
B. Furosemide
C. Hydrochlorothiazide
D. Losartan
MKSAP Answer and Critique
The correct answer is B. Furosemide. This content is available to MKSAP 18 subscribers as Question 100 in the Nephrology section. More information about MKSAP is available online.
The addition of a loop diuretic such as furosemide is the most appropriate treatment. This patient has difficult-to-control hypertension in the setting of stage G4 chronic kidney disease (CKD), and his blood pressure is not at target. The American College of Cardiology/American Heart Association blood pressure guideline recommends a target blood pressure of <130/80 mm Hg for all patients, including those with CKD. The most appropriate treatment is the addition of a loop diuretic. Suboptimal blood pressure therapy in patients with difficult-to-control hypertension is frequently the result of not including a diuretic, which prevents or corrects extracellular volume expansion. Persistent volume expansion, even if not sufficient to produce clinically evident edema, contributes significantly to hypertension. This is particularly important in sodium-retentive, edematous conditions such as heart failure, liver cirrhosis, or CKD.
Although thiazide diuretics are frequently used as initial diuretic therapy, they are generally less effective in patients with lower glomerular filtration rates. At estimated glomerular filtration rates <30 mL/min/1.73 m2, loop diuretics tend to be more effective at controlling extracellular volume expansion and should be used instead of (or added to) thiazide diuretics. The dosage of loop diuretics depends on the sodium intake and the severity of CKD. Generally, furosemide doses of 40 to 80 mg twice daily is initiated with a salt-restricted diet and adjusted according to the response. When it is appropriate to add a thiazide diuretic to a blood pressure regimen, chlorthalidone is often preferred because of its longer duration of action.
The patient is already on a maximum dose of the ACE inhibitor lisinopril, which is appropriate for the treatment of hypertension in patients with CKD. Although he still has albuminuria, addition of the angiotensin receptor blocker (ARB) losartan is inappropriate because several trials have shown that combination therapy with an ACE inhibitor and ARB may result in adverse events, such as acute kidney injury and hyperkalemia, and does not improve cardiovascular outcomes compared with treatment with an ACE inhibitor or ARB alone.
Key Point
- Patients with difficult-to-control hypertension typically require the addition of a diuretic, which prevents or corrects extracellular volume expansion in sodium-retentive, edematous conditions (heart failure, liver cirrhosis, chronic kidney disease).