title: Thiazide diuretics in advanced chronic kidney disease.
abstract: Chronic kidney disease (CKD) is prevalent in 3%-4% of the adult population in the United States, and the vast majority of these people are hypertensive. Compared with those with essential hypertension, hypertension in CKD remains poorly controlled despite the use of multiple antihypertensive drugs. Hypervolemia is thought to be a major cause of hypertension, and diuretics are useful to improve blood pressure control in CKD. Non-osmotic storage of sodium in the skin and muscle may be a novel mechanism by which sodium may modulate hypertension; further work is need to study this novel phenomenon with diuretics. Among people with stage 4 CKD, loop diuretics are recommended over thiazides. Thiazide diuretics are deemed ineffective in people with stage 4 CKD. Review of the literature suggests that thiazides may be useful even among people with advanced CKD. They cause a negative sodium balance, increasing sodium excretion by 10%-15% and weight loss by 1-2 kg in observational studies. Observational data show improvement in seated clinic blood pressure of about 10-15 mm Hg systolic and 5-10 mm Hg diastolic, whereas randomized trials show about 15 mm Hg improvement in mean arterial pressure. Volume depletion, hyponatremia, hypokalemia, hypercalcemia, and acute kidney injury are adverse effects that should be closely monitored. Our review suggests that adequately powered randomized trials are needed before the use of thiazide diuretics can be firmly recommended in those with advanced CKD.
authors.affiliation: Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN 46202, USA. ragarwal@iupui.edu
authors.forename: Rajiv
authors.initials: R
authors.lastname: Agarwal
authors.forename: Arjun D
authors.initials: AD
authors.lastname: Sinha
mesh_terms: D000328:Adult; D000818:Animals; D000959:Antihypertensive Agents / Q000627:therapeutic use; D055592:Biophysical Phenomena / Q000187:drug effects; D001794:Blood Pressure / Q000187:drug effects*; D001810:Blood Volume / Q000187:drug effects*; D018450:Disease Progression; D016903:Drug Monitoring / Q000379:methods; D004351:Drug Resistance; D005919:Glomerular Filtration Rate; D006801:Humans; D006973:Hypertension / Q000188:drug therapy / Q000209:etiology / Q000378:metabolism / Q000503:physiopathology; D054539:Medication Therapy Management; D023421:Models, Animal; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D051381:Rats; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000188:drug therapy / Q000378:metabolism / Q000503:physiopathology; D012964:Sodium / Q000378:metabolism*; D049993:Sodium Chloride Symporter Inhibitors / Q000008:administration & dosage / Q000009:adverse effects / Q000493:pharmacokinetics; D049994:Sodium Potassium Chloride Symporter Inhibitors / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D000959:Antihypertensive Agents; D049993:Sodium Chloride Symporter Inhibitors; D049994:Sodium Potassium Chloride Symporter Inhibitors; D012964:Sodium