How is chronic kidney disease secondary to hypertension controlled?

From the Guidelines

Controlling chronic kidney disease (CKD) secondary to hypertension requires aggressive blood pressure management with a target systolic BP of 120–129 mmHg, if tolerated, alongside kidney-protective strategies. The management of CKD secondary to hypertension involves a multifaceted approach that includes lifestyle modifications and pharmacological interventions.

• Lifestyle modifications are essential and include limiting dietary sodium to less than 2 grams daily, maintaining a healthy weight, exercising regularly (150 minutes of moderate activity weekly), avoiding nephrotoxic medications like NSAIDs, and managing comorbidities such as diabetes (target HbA1c <7%) 1.
• First-line medications include angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), which not only lower blood pressure but also reduce proteinuria and slow CKD progression by decreasing intraglomerular pressure 1.
• Additionally, SGLT2 inhibitors are recommended for hypertensive patients with CKD and eGFR >20 mL/min/1.73 m² to improve outcomes, given their modest BP-lowering properties 1.
• Regular monitoring of kidney function with serum creatinine, estimated glomerular filtration rate (eGFR), and urine albumin-to-creatinine ratio every 3-6 months helps track disease progression and medication effectiveness.
• The choice of antihypertensive medication and target blood pressure may need to be individualized based on the patient's specific condition, including the presence of diabetes, the level of kidney function, and tolerance to treatment 1.
• It is also important to consider the potential benefits and risks of aggressive blood pressure control, particularly in patients with more advanced CKD or those at high risk of cardiovascular disease 1.

From the FDA Drug Label

The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]). Treatment with losartan resulted in a 16% risk reduction in this endpoint (see Figure 4 and Table 4) Treatment with losartan also reduced the occurrence of sustained doubling of serum creatinine by 25% and ESRD by 29% as separate endpoints, but had no effect on overall mortality (see Table 4).

Control of Chronic Kidney Disease Secondary to Hypertension:

• The control of chronic kidney disease secondary to hypertension involves the use of angiotensin II receptor antagonists such as losartan.
• Losartan has been shown to reduce the risk of doubling of serum creatinine and end-stage renal disease (ESRD) by 25% and 29%, respectively.
• The use of losartan in combination with conventional antihypertensive therapy can help to achieve blood pressure goals and reduce the risk of cardiovascular events.
• Blood pressure control is an essential part of the management of chronic kidney disease secondary to hypertension, and losartan can be used to help achieve this goal 2.

From the Research

Controlling Chronic Kidney Disease Secondary to Hypertension

Controlling chronic kidney disease (CKD) secondary to hypertension involves a combination of lifestyle modifications and medical therapies. The primary goal is to reduce blood pressure to a target level of <130/80 mmHg in patients with CKD and albuminuria 3, 4, 5, 6.

Lifestyle Modifications

Lifestyle modifications play a crucial role in controlling CKD secondary to hypertension. These include:

• Maintaining a healthy body weight 7
• Moderating alcohol consumption 7
• Regular exercise 7
• Reducing sodium intake 7
• Altering intake of calcium, magnesium, and potassium 7
• Reducing stress 7
• Adhering to a low-protein diet (LPD) and the alternate Mediterranean (aMed) diet or Alternative Healthy Eating Index (AHEI)-2010 5

Medical Therapies

Medical therapies for controlling CKD secondary to hypertension include:

• Angiotensin-converting enzyme (ACE) inhibitors as the first-line treatment 3, 4, 6
• Angiotensin II receptor blockers (ARBs) as an alternative to ACE inhibitors 3, 4, 6
• Non-dihydropyridine calcium channel blockers (CCBs) to reduce albuminuria and slow the decline in kidney function 3
• Dihydropyridine CCBs in combination with a renin-angiotensin-aldosterone system (RAAS) blocker 3
• Diuretics as a cornerstone in the management of CKD patients 3, 6
• Sodium-glucose cotransporter-2 (SGLT2) inhibitors, pentoxifylline, and finerenone as approved treatments for managing CKD 5
• Emerging agents such as non-steroidal mineralocorticoid receptor antagonists, dual endothelin receptor antagonists, and aldosterone synthase inhibitors as novel targets and strategies to control blood pressure 6