[Professor’s name appears here]
[University name appears here]
[Date appears here]
Restate question
Do patients suffering from End stage renal disease (ESRD) have the renal protective benefit from usage of Angiotensin receptor blockers (ARBs) or Angiotensin converting enzyme inhibitors (ACEI)?
Provide background information(in 4 sentences) ; please paraphrase the paragraph below
Patient presented with deteriorating symptom of renal failure. Patient has a past medical history of hypertension, end stage renal disease, dyslipidemia, uncontrolled diabetes mellitus, neuropathy and PVD. The dialysis started in 2000 and her renal transplant is scheduled in the next six months. Prior to her kidney transplant, she has been referred to a tobacco cessation clinic to minimize the postoperative risks and complications. At the time of presentation in the clinic, her blood pressure and heart rate, both were elevated. She has been advised to take carvedilol 25mg twice daily along with doxazosin 20mg twice daily. Both her medications are oral medicine. Based on her current mediaction and in light of the guidelines, it is strongly advised that she should stop taking doxazosin owing to its relatively high dose in a patient with ESRD. There are better options available to control her hypertension like ACEI or ARB. Both ARBs and ACEIs are first line therapy for patients with hypertension, diabetes melitus and ESRD and have shown better outcomes in terms of tolerance and morbidity.
And here we have to add a paragraph of supporting comments from guidelines (the link is below) that support the use of ACEI or ARBS in dialysis patient with hypertension; (Please paraphrase the words and add additional supporting sentences from link below)
There are certain blood pressure goals that are supposed to be achieved in a patient undergoing dialysis. Prior to the procedure of dialysis, blood pressure should remain lower than 140/90 mmHg while post-procedure, it should remain less than 130/80mmHg.
Drugs that are responsible to inhibit Angiotensin converting enzyme or block the angiotensin receptor have multitude of benefits in controlling hypertension in a morbidly ill patient. There therapeutic effects include:
Massive reduction in left ventricular hypertrophy
Reduced sympathetic activity
Decreased pulse wave velocity
Enhancement of endothelial function
Decreased oxidative stress
ACEIs and ARBs are the first line treatment of choice in patients undergoing dialysis with hypertension. In refractory cases, it is advised to add a third treatment line which is preferably a calcium channel blocker (CCB).
ACEIs and ARBs constrict the efferent arteriole in the glomerulus which significantly decreases the renal plasma flow and increases the glomerular filtration rate (GFR). Increased GFR causes enhanced excretion of glucose.
Describe literature support(in 2 paragraphs)
It has been concluded that cardiovascular disease is one of the most leading cause of mortality in patients with end stage renal disease. And among those cardiovascular diseases, hypertension is a major risk factor. According to a study conducted by Efrati et al. (2002), ACEIs and ARBS are the most effective treatment modalities present for the management of HTN in patients with ESRD. A total of 126 patients were enrolled in a study to assess the effects of ACEIs on mortality of patients suffering from ESRD. Patients on hemodialysis were included from 1994 till 2000. Two groups were made; first group had 60 patients and they were treated with ACEI while the second group had 66 patients and they were not given ACEI and 24 [atients from group 1 were on insulin while 25 were from group 2. The exclusion criteria from the study were:
Patient on a dialysis of less than 1 year duration
Kidney transplanted
Left the hemodialysis
Patient with mean Kt/V of less than 1
The patients were followed up every 6 months and parameters like systolic blood pressure, diastolic blood pressure, Kt/V, albumin and hemoglobin levels were assessed. The mean age of the patients inducted were 64.3 with standard deviation of 13.7 and mean diastolic blood pressure values were same in both the groups i.e., 78.7 with standard deviation of 11.4. This study significantly concluded that patients who are 65 years old or younger have statistically better treatment outcomes. The mortality rate was decreased by 79% in such individuals and it has a p value or less than 0.0006. Although, mean systolic pressures were higher in the group that was treated and had 143 mmHg as compared with 132.5 mmHg of the control group. Unfortunately, from the treated group, 5 patients had cardiac death while 19 patients died from the untreated group with the p value of less than 0.0003.
Although, it is noteworthy that blood pressure goals were same in both groups but mortality was significantly decreased in the treated group. In the first group who were given ACEI, they showed mortality reduction in patients aged 65 or less to approximately 79%.the authors concluded that the anti-hypertensive effects of ACEI might be minimal but they have shown to drastically decrease mortality in individuals with ESRD and hypertension. The limitation of this study spans around the fact that the testing done was preliminary and did not take into account other important factors. The study is a retrospective study and there are unclear information like the type of ACEI used and dose adjustment on patients undergoing dialysis. Therefore, further research in the form of prospective study or a clinical trial is warranted before the results can be generalized.
Similarly, according to Cravedi et al. (2011), single hypertensive class that has the highest cardioprotective effect in patients with ESRD, DM and HTN altogether is ACEIs and ARBs. Authors also mentioned that sufficient quality data is present currently to support that ACEIs and ARBs decrease mortality and morbidity both in a co-morbid patient. It also conserves the residual renal function during various dialysis modalities. They are very well tolerated and they should be used as first line therapy in suitable individuals as discussed in the previous text. Similarly, the limitation this article showed that these drugs didn’t show any superiority as an anti-hypertensive and a great space is still present over which research can be done to formulate a generalized conclusion.
Formulate conclusion (in 3 sentences)
Based on the above mentioned facts and in liht of current guideline made through research, it should be made sure that patients who have ESRD, DM and HTN should be initiated with ACEIs or ARBs as first line treatment. The drugs are well tolerated, efficiently control blood pressure and significantly decrease mortality and morbidity.
References
Cravedi, P., Remuzzi, G., & Ruggenenti, P. (2011). Targeting the Renin Angiotensin System in Dialysis Patients. Seminars In Dialysis, 24(3), 290-297. http://dx.doi.org/10.1111/j.1525-139x.2011.00939.x
Efrati, S., Zaidenstein, R., Dishy, V., Beberashvili, I., Sharist, M., & Averbukh, Z. et al. (2002). ACE inhibitors and survival of hemodialysis patients. American Journal Of Kidney Diseases, 40(5), 1023-1029. http://dx.doi.org/10.1053/ajkd.2002.36340
