The Curbsiders Internal Medicine Podcast #386 Primary Aldosteronism, MRAs, and Renovascular Hypertension: NephMadness Pod Crawl 2023
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Mar 20, 2023 AI Snips
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Optimize Diuretic And Add SGLT2 In CKD
- Switch hydrochlorothiazide to chlorthalidone 25 mg for more potent, renoprotective BP lowering in CKD.
- Add an SGLT2 inhibitor for CKD with albuminuria, which also helps offset potassium rises when starting MRAs.
Aldosterone Causes Hyperfiltration
- Unopposed aldosterone causes glomerular hyperfiltration that can mask underlying kidney damage.
- Treating PA (medical or surgical) commonly raises creatinine acutely by reversing hyperfiltration but benefits long-term renal outcomes.
Start Low And Titrate MRAs Carefully
- Start spironolactone at 12.5 mg and titrate up checking potassium and creatinine within 1–2 weeks.
- Expect to push doses up (often to ~100 mg) for bilateral hyperplasia but be limited by hyperkalemia in CKD.