From the Guidelines
The management of chronic kidney disease (CKD) in patients with uncontrolled hypertension should prioritize blood pressure control and kidney protection, with a target blood pressure of <130/80 mmHg, using a combination of lifestyle modifications and pharmacological agents, including angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) as first-line therapy, as recommended by the most recent guidelines 1.
Key Components of Management
- Lifestyle modifications: sodium restriction (<2g daily), regular physical activity, weight management, smoking cessation, and limiting alcohol intake
- Pharmacological agents:
- First-line therapy: ACEIs (e.g., lisinopril 10-40 mg daily) or ARBs (e.g., losartan 50-100 mg daily)
- Additional antihypertensives: thiazide diuretics (e.g., chlorthalidone 12.5-25 mg daily) or loop diuretics (e.g., furosemide 20-80 mg twice daily)
- Calcium channel blockers (e.g., amlodipine 5-10 mg daily) as effective additions
Monitoring and Adjustments
- Regular monitoring of blood pressure, kidney function, electrolytes, and proteinuria
- Adjustments to medication regimens as needed to achieve target blood pressure and slow CKD progression
Considerations for Resistant Hypertension
- Reinforcement of lifestyle measures, especially sodium restriction
- Addition of low-dose spironolactone to existing treatment, or further diuretic therapy if intolerant to spironolactone 1
- Consideration of catheter-based renal denervation for resistant hypertension patients who have uncontrolled blood pressure despite a three-drug combination, and who express a preference to undergo renal denervation after a shared risk-benefit discussion and multidisciplinary assessment 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Management of Chronic Kidney Disease in Uncontrolled Hypertensive Patients
The management of chronic kidney disease (CKD) in patients with uncontrolled hypertension is crucial to slow disease progression and reduce cardiovascular risk. According to 2, control of hypertension is important in those with CKD as it leads to slowing of disease progression as well as reduced cardiovascular disease (CVD) risk.
Key Considerations
- Non-pharmacological interventions are useful in reducing blood pressure (BP) in CKD but are rarely sufficient to control BP adequately 2.
- Patients with CKD and hypertension will often require a combination of antihypertensive medications to achieve target BP 2, 3.
- Certain pharmacological therapies provide additional BP-independent renoprotective and/or cardioprotective action and this must be considered when instituting therapy 2.
Pharmacological Interventions
- Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are recommended for patients with CKD as they reduce the risk of cardiovascular events and delay end-stage kidney disease 4.
- ACEIs monotherapy significantly decreased the odds of kidney events, cardiovascular events, cardiovascular death, and all-cause death when compared to placebo 4.
- Combination therapy of an ACEI plus an ARB showed no more advantage than calcium channel blockers (CCBs), β-blockers, and diuretics on primary outcomes except for kidney events 4.
Lifestyle Modifications
- Lifestyle modifications, including dietary salt restriction, are important in managing hypertension in CKD patients 3, 5.
- Patient education and engagement are crucial in improving outcomes and fostering adherence to treatment plans 5.