The role of combination antihypertensive therapy in the prevention and treatment of chronic kidney disease.
The failure to achieve blood pressure (BP) control in the general population makes a substantial contribution to the development of chronic kidney disease (CKD) and subsequent renal failure. Each year, in the United States, more than 94,000 people develop end-stage renal disease; about 65% of these cases are directly attributable to hypertension and diabetes. Like hypertension, CKD does not produce symptoms for many years, and therefore its detection, prevention, and treatment are largely dependent on the vigilance of physicians and other health care providers. Current therapeutic advances make it possible to slow the progression of CKD and to improve clinical outcomes for these patients. Large, randomized, clinical hypertension trials have shown that tighter BP control, compared with less tight BP control, can reduce progression of renal disease by 30% to 50% and cardiovascular disease by 40% to 70%. Achieving BP levels of <130/80 mm Hg, as currently recommended for patients with diabetes or CKD, will often require three or more antihypertensive medications. Furthermore, reduction of BP should be accompanied by reductions in albuminuria and proteinuria to maximize potential benefits to the kidney. Evidence from numerous randomized controlled trials mandate that agents that block the renin-angiotensin system should always be included in the antihypertensive regimens of patients with CKD, particularly with the excellent safety data with serum creatinine levels <3 to 4 mg/dL. Fixed-dose combination agents are useful in bringing high-risk hypertensive patients to appropriate BP goals, primarily by simplifying the complex medical regimens in these patients.