Do ACE inhibitors or angiotensin II receptor blockers (ARBs) offer renal protection to patients with diabetes or renal disease?— Negeen Farmand, PA-C, Los Angeles

When should a clinician stop an ACE inhibitor in a diabetic patient with renal failure? — Atul Sharma, PA-C, MMS, MPH, CHES, Sacramento, Calif.

The most effective method to prevent diabetic nephropathy is tight glycemic control and control of BP and cholesterol. Weight reduction, exercise, and avoidance of smoking also help. However, even with the best control, the kidneys are apt to be affected by the disease state.


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ACE inhibitors and ARBs have been shown effective in preventing or at least slowing the process of renal disease in patients with diabetes by interfering with the renin-angiotensin system. ACE inhibitors and ARBs lower intraglomerular pressure by decreasing efferent arteriolar pressure. If BP remains elevated, additional medication is warranted; consider diuretics, cardioselective beta-blockers, or nondihydropyridine calcium channel blockers (dihydropyridine calcium channel blockers [verapamil, diltiazem] raise intraglomerular pressure, thereby increasing risk of nephropathy).

Use of ACE inhibitors or ARBs is recommended for Stage 1, 2, and 3 renal failure. If the glomerular filtration rate falls to Stage 4 levels and the patient exhibits marked proteinuria, dialysis or transplant is recommended. — Claire Babcock O’Connell, MPH, PA-C (153-02)

I’m a nephrologist and this posting is patently wrong. The minor error is that you incorrectly identify dihydropyridine CCBs as verapamil and diltiazem. Those are non-DHP CCBs. You meant to say nifedipine, amlodipine and felodipine.
 
The major mistake is that you recommend starting dialysis with stage 4 CKD. That would be malpractice. Dialysis is to be considered for stage 5 CKD. ACE/ARB therapy should be continued as long as tolerated by hyperkalemia, throughout stage 4 CKD, and sometimes into stage 5 CKD as long as uremic symptoms are not significant.  Daniel Levy, MD, PhD, submitted via email

Thank you for the correction regarding verapamil and diltiazem. I apologize for the error. As for the second comment, patients in stage 4 kidney disease will likely need dialysis or transplant very soon. Perhaps it is more accurate to say dialysis or transplant is considered (rather than recommended) in such cases. The decision to place a patient on dialysis depends on many factors, not just the glomerular filtration rate (GFR), which is what determines the stage of kidney disease. Many patients do go on dialysis when the GFR falls to stage 4 levels. — Claire Babcock O’Connell, MPH, PA-C (155-19)