Medication Summary

The general approach to therapy of ischemic nephropathy involves control of hypertension, preferably with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). Unfortunately, these two classes of drugs may lead to increased serum creatinine levels and hyperkalemia, limiting their utility. In this case, calcium channel blockers are likely the most useful and best-tolerated agents.

Initiate strict control of serum cholesterol, which usually requires the use of statins, as with all conditions associated with atherosclerosis. A study by Bianchi et al suggested that statins, in addition to ACE inhibitors and ARBs, may reduce proteinuria and slow the progression of kidney disease.^[69]

Class Summary

These agents decrease aldosterone secretion.

Captopril (Capoten)

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Parent compound of this class of medications. Sulfhydryl group associated with proteinuria and neutropenia when used at high doses. Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.

Enalapril (Vasotec)

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One example of this class of compounds. Similar precautions to captopril with respect to potential increase in potassium and creatinine. Major adverse effect is dry cough. Newer and, occasionally, better tolerated than parent compound. Many variations that allow for once-daily dosing and better tissue ACE inhibition.

Class Summary

Useful for hypertension and heart failure in patients who are intolerant of ACE inhibitors. Many alternative compounds exist with few significant clinical differences.

Losartan (Cozaar)

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Initial compound in class to gain approval. Useful for treatment of hypertension and heart failure in patients who are intolerant of ACE inhibitors. Many alternative compounds exist with few significant clinical differences. Nonpeptide angiotensin II receptor antagonist that blocks the vasoconstricting and aldosterone-secreting effects of angiotensin II. May induce a more complete inhibition of the renin-angiotensin system than ACE inhibitors, does not affect the response to bradykinin, and is less likely to be associated with cough and angioedema. For patients unable to tolerate ACE inhibitors.

Class Summary

Adjunct to diet to reduce total and LDL cholesterol in patients with hypercholesterolemia. Also lower triglycerides.

Atorvastatin (Lipitor)

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One of many compounds with comparable efficacy and adverse effect profiles. Inhibits HMG-CoA reductase, which, in turn, inhibits cholesterol synthesis and increases cholesterol metabolism.

Questions

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Media Gallery

Renal artery stenosis/renovascular hypertension. Left, Sonograms of the kidneys on a 57-year-old woman with difficult-to-control hypertension shows kidneys of uneven sizes: The left kidney is 96 mm, and the right kidney is 63 mm. Top right, Isotopic renogram (obtained with technetium mercaptoacetyltriglycine [MAG3]) after captopril shows a markedly depressed renal function in the right kidney. Bottom right, Analogous images show negligible activity in the right kidney. Note that this pattern is more typical for DTPA than MAG3 (as DTPA depends on the glomerular filtration rate for uptake which is decreased after captopril in renovascular hypertension [RVHT]). In severe cases of RVHT, MAG3 uptake can be decreased, as in this case. However, typically, uptake is preserved with decreased cortical excretion.
Renal artery stenosis/renovascular hypertension. Left, Flush aortogram in a 63-year-old man with hypertension shows marked stenosis of the right renal artery and complete occlusion of the left renal artery. Note the extensive atheroma in the aorta and iliac arteries. Right, nephrogram-phase image shows a significantly smaller left kidney with a faint nephrogram. Some blood supply to the left kidney is retained via collaterals (see image on the left).
Renal artery stenosis/renovascular hypertension. Flush aortogram in a 32-year-old man with familial hypercholesterolemia and difficult-to-control hypertension. Radiograph shows a complete occlusion of the right renal artery and marked stenosis of the left renal artery (arrow).
Three-dimensional gadolinium-enhanced magnetic resonance angiograms (MRAs) show medial fibroplasia, which appears as classic string-of-beads sign. This sign is due to multiple stenoses with intervening outpouchings that form a chain. In this case, the lesions involve the main right renal artery and the right accessory renal artery in a 37-year-old man with difficult-to-control hypertension.
Conventional flush aortogram in a 47-year-old woman with difficult-to-control hypertension shows the characteristic string-of-beads sign (arrows) of the right renal artery due to medial fibroplasia.

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Author

Bruce S Spinowitz, MD, FACP Clinical Professor of Medicine, Weill Medical College of Cornell University; School of Medicine; Associate Chairman, Associate Director and Attending Physician, Department of Medicine, Division of Nephrology, New York Hospital Medical Center Queens; Associate, Nephrology Associates, PC

Bruce S Spinowitz, MD, FACP is a member of the following medical societies: American College of Physicians, International Society for Peritoneal Dialysis, Renal Physicians Association, American Society of Nephrology, International Society of Nephrology

Disclosure: Received grant/research funds from AMAG Pharmaceuticals for independent contractor; Received grant/research funds from Amgen for independent contractor; Received grant/research funds from Vifor for independent contractor; Received grant/research funds from Hospira for independent contractor; Received grant/research funds from Relypsa for independent contractor; Received grant/research funds from Akebia for independent contractor; Received grant/research funds from ZS Pharma for none.

Coauthor(s)

Joanna M Rodriguez, MD Nephrologist, Memorial Healthcare System

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Society of Nephrology<br/>Received income in an amount equal to or greater than $250 from: Healthcare Quality Strategies, Inc.

Chief Editor

Vecihi Batuman, MD, FASN Professor of Medicine, Section of Nephrology-Hypertension, Deming Department of Medicine, Tulane University School of Medicine

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

Donald A Feinfeld, MD, FACP, FASN Consulting Staff, Division of Nephrology and Hypertension, Beth Israel Medical Center

Disclosure: Nothing to disclose.

Renal Artery Stenosis Medication

Medication Summary

Angiotensin-converting enzyme inhibitors