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  Sunday, 16 November 2014
  3 Replies
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Hello:  My now 58 yo husband was on atenolol & hctz for 4 years for HBP.. kidney function went from 70% to 50% eFGR, doctors said no biggie, I am thinking "where will he be in the next 4 years"?  Through diet & exercise we got him off of meds ... lasted 2 years, bad habits and central apnea he had to go back on meds.. at onset of meds kidney function was 62%.  Two years on ramipril and kidney function is now 54% and they want to add hctz now ... doctor is saying his function is good and I am worrying about nothing.  I agree his function is adequate now but at an average rate of 4-5% loss each year .. where is it going to lead?  I am worried about this yearly loss of function on the meds he is on but our concerns are poo ***** ... I would like to see him on meds that don't have a history of affecting kidneys ... hctz.. has 6 potential effects on the kidneys according to the CPS ... doctors are saying it doesn't affect kidneys at all???  I would like to just trust what they are saying but a red flag is flying for me right now.  Can I get your feedback on this please.  thank you
Hello, Diuretics are routinely used to treat hypertension, even in high-risk individuals such as those with diabetes. In fact, nearly all ACE inhibitors or angiotensin receptor blockers use HCTZ in a fixed dose combination tablet. Having said this, diuretics can cause some adverse effects (e.g. elevated LDL, glucose, uric acid, volume contraction) but they can easily be monitored clinically and with blood tests. Most contemporary dosing of diuretics which is typically lower than what was used in the past, poses less risk for these adverse events. Nevertheless, there are other options besides diuretics; I have been increasingly using calcium channel blockers such as amlodipine in combination with ACE inhibitors like ramipril due to positive results from the ACCOMPLISH study. Regarding your husband's renal function, I don't have enough information to comment completely. It would be important to know his urinary protein numbers and results of abdominal ultrasound to be able to answer more completely. If he lacks significant proteinuria or signs and symptoms of systemic disease that could lead to renal problems, the priority would be blood pressure control, and provided his function stabilizes, his physicians are correct to reassure you. I would avoid extrapolating too much from small, relatively short-term changes in kidney function to predict long-term outcomes. Regards, Dr. Jordan Weinstein
9 years ago
Thanks for your time in replying.  We went in to see the NP last week thinking she may be more open ... she at least listened to my concerns about his Cheyne Stoke breathing with apnea up to 20 seconds, the other doctor dismissed, we had some home monitoring done and waiting for results.  It seems that they are focusing on the BP and not what could be causing it.  Anyhow, went back in today and asked if he could have an EKG because of his arrythmia, they don't know that because they don't even auscultate anymore?? anyhow he is going to get a 3 lead on Friday .. beggers can't be choosers.  I asked about whether they forgot to take a urine sample the previous week and she said they don't do them anymore unless you are presenting with symptoms?? I guess apnea, elevated BP, arrythmias are not symptoms??  I don't understand it. Anyhow, you mention the ACCOMPLISH study and it showed that ACEI in combination with HCTZ actually increased the risk of CV mortality, stroke and progression of chronic kidney dx by 25%, 18% and 90% respectively.   that is a bit of a concern The NP won't alter the drugs as she has been prescribing them for years with no problems.  She recommended talking to another doctor that is up on his meds. Kidney function, I see what you mean .. two weeks ago eFGR was 54 and then a week later another blood test because his potassium was 6.0 and his eFGR is now 60% ... how can it fluctuate so much?? Anyhow, thank you ... I wished we lived in a different location than we do but, we are stuck with the resources we have right now and a specialist is only seen on a referral.  Unfortunately for those around these parts, if the doctors are presented with things beyond their scope they don't send you to someone who knows, they send you home................... sorry for ranting.
Sleep apnea is a well-known contributor to resistant hypertension. And so in light of the breathing symptoms he is experiencing, it might be worthwhile to undergo  asleep study. Of course, other causes of dyspnea should be considered (congestive heart failure, COPD etc). If his potassium does approach 6 on an ACE inhibitor, this is concerning. He should follow a low potassium diet, [url=nephrology-resources/nephrology-nutrition/item/chronic-kidney-disease-nutrition-fact-sheets-potassium]available here[/url]. Alternatively, HCTZ may indeed be useful as it does keep potassium levels down. And yes, GFR can indeed fluctuate such as you describe. Where are you in the world? Dr. Jordan Weinstein
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