A 54-year-old man presents to the outpatient clinic for management of his blood pressure. He reports feeling well and does not have any complaints. Medical history is significant for hypertension and stage 4 chronic kidney disease with proteinuria that has been quantified at ≥3.5 g/day. The patient states he is compliant with his current medications which are lisinopril and nifedipine. He reports eating a “heart healthy diet.” He is afebrile with a blood pressure of 152/90 mmHg, heart rate of 78 beats/min, respirations of 18/min, and a body mass index (BMI) of 29 kg/m2. Physical examination shows jugular venous distension of > 4 cm above the sternal angle. Cardiac examination reveals an S4 that occurs during late diastole. Lungs are clear to auscultation without wheezing or crackles. There is 1+ bilateral pitting edema in the lower extremities. The remainder of the examination is otherwise unremarkable.
Laboratory studies reveal the following:
Sodium: 137
Potassium: 5.1
Chloride: 94
Bicarbonate: 22
BUN: 21
Creatinine: 2.6
eGFR: 25
Glucose: 124
Calcium: 8.2
Which of the following is the most appropriate additional medical therapy according to the current American College of Cardiology / American Heart Association (ACC/AHA) blood pressure guidelines?
The correct answer is:
C) Furosemide
This patient has an elevated blood pressure not controlled to a target goal of <130/80 mm Hg according to ACC/AHA guidelines. A loop diuretic such as furosemide is indicated for treating hypertension in patients with advanced chronic kidney disease as seen with this patient who also has clinical findings of increased extracellular fluid volume. Loop diuretics are preferred in patients with chronic kidney disease and GFR < 30.
Answer choice A: Candesartan, is incorrect. The patient already takes lisinopril, and combination therapy with an angiotensin converting enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) may result in adverse events, such as acute kidney injury and hyperkalemia.
Answer choice B: Chlorthalidone, is incorrect. A thiazide diuretic will unlikely be effective in patients with stage 4 or 5 chronic kidney disease, and the patient’s estimated GFR is <30 mL/min.
Answer choice D: Hydralazine, is incorrect. Hydralazine will lower the blood pressure but will not address the patient’s fluid overload status.
Answer choice E: Metoprolol succinate, is incorrect. Without indications such as coronary artery disease or congestive heart failure, the addition of a β-blocker is not appropriate.
Key Learning Point
Loop diuretics are second-line therapy for hypertension but are preferred in patients with chronic kidney disease and a GFR < 30 as thiazides are less effective in these cases. Loop diuretics are also indicated in severe heart failure.
