What is the best hypertension management for a 71-year-old female with Chronic Kidney Disease (CKD)?

From the Guidelines

For a 71-year-old female with hypertension and chronic kidney disease (CKD), I recommend a target blood pressure of less than 130/80 mmHg, as suggested by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

Key Recommendations

• First-line medication should be an angiotensin-converting enzyme inhibitor (ACE inhibitor) such as lisinopril starting at 5-10 mg daily or an angiotensin receptor blocker (ARB) like losartan 25-50 mg daily, as they not only lower blood pressure but also reduce proteinuria and slow CKD progression 1.
• If the target blood pressure is not achieved with a single agent, add a long-acting calcium channel blocker such as amlodipine 5-10 mg daily.
• For patients who need additional therapy, a thiazide-like diuretic such as chlorthalidone 12.5-25 mg daily can be added, but with careful monitoring of kidney function and electrolytes.
• Loop diuretics like furosemide may be needed instead of thiazides if the estimated glomerular filtration rate (eGFR) is below 30 ml/min.

Lifestyle Modifications

• Sodium restriction (less than 2 grams daily) is crucial, as it helps to optimize the effectiveness of medication used to control blood pressure 1.
• Regular physical activity, weight management, and avoiding NSAIDs are also essential components of management.

Monitoring

• Regular monitoring of blood pressure, kidney function, potassium, and albuminuria is essential, with checks every 2-4 weeks after medication changes and then every 3-6 months once stable. The 2024 ESC guidelines 1 provide the most recent and highest quality evidence for the management of hypertension in patients with CKD, and their recommendations should be prioritized in clinical practice.

From the Research

Hypertension Management for a 71-Year-Old Female with CKD

• The management of hypertension in a 71-year-old female with chronic kidney disease (CKD) involves a combination of lifestyle modifications and pharmacological interventions 2.
• Lifestyle modifications include adhering to a healthy diet, performing regular physical activity, managing body weight, abstaining from tobacco use, and limiting alcohol consumption 2.
• Pharmacological interventions may involve the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), which are commonly prescribed for patients with CKD 3.
• The combination of an ACEI and an ARB may be more effective in reducing urine albumin excretion and urine protein excretion, but it also increases the risk of hyperkalemia and hypotension 4.
• Another option is the combination of an ARB with a calcium channel blocker (CCB) or a diuretic, which has been shown to be effective in controlling blood pressure and slowing the progression of CKD 5.
• Nutrition education and counseling are also important components of CKD management, and dietitians play a crucial role in helping patients with CKD make informed food choices 6.

Pharmacological Interventions

• ACEIs and ARBs are commonly used to manage hypertension in patients with CKD 3.
• The combination of an ACEI and an ARB may be more effective in reducing urine albumin excretion and urine protein excretion, but it also increases the risk of hyperkalemia and hypotension 4.
• The use of CCBs or diuretics in combination with an ARB may be a viable alternative for patients who cannot tolerate ACEIs or ARBs 5.

Lifestyle Modifications

• Adhering to a healthy diet is essential for managing CKD and controlling blood pressure 2.
• Regular physical activity, such as walking or other aerobic exercises, can help improve cardiovascular health and reduce blood pressure 2.
• Managing body weight, abstaining from tobacco use, and limiting alcohol consumption are also important lifestyle modifications for patients with CKD 2.