From the Guidelines
The recommended treatment for severe hypertension in patients with kidney disease is to start with renin-angiotensin-system inhibitors (RASi), such as angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB), with a target blood pressure goal of less than 130/80 mmHg. This approach is supported by the most recent and highest quality study, which suggests that RASi should be started for people with high blood pressure, chronic kidney disease (CKD), and severely increased albuminuria 1.
First-Line Therapy
The first-line therapy for severe hypertension in patients with kidney disease typically involves a combination of ACE inhibitors or ARBs, such as lisinopril (10-40 mg daily), enalapril (5-40 mg daily), or losartan (25-100 mg daily) 1. These medications should be started at lower doses and gradually increased to reach the target blood pressure goal.
Additional Agents
A diuretic is often added as a second agent, with thiazide diuretics like hydrochlorothiazide (12.5-25 mg daily) for mild-moderate kidney disease, or loop diuretics such as furosemide (20-80 mg twice daily) for more advanced kidney disease 1. Calcium channel blockers like amlodipine (5-10 mg daily) are frequently added as a third agent.
Resistant Hypertension
For resistant hypertension, beta-blockers (metoprolol 25-200 mg daily) or aldosterone antagonists (spironolactone 25-50 mg daily, with careful potassium monitoring) may be necessary 1. These medications are effective because they not only lower blood pressure but also reduce proteinuria and slow kidney disease progression.
Key Considerations
ACE inhibitors and ARBs specifically decrease intraglomerular pressure and provide renoprotective effects beyond blood pressure control 1. Regular monitoring of kidney function, electrolytes, and blood pressure is essential, with medication adjustments as needed based on response and tolerance. It is also important to avoid any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy in patients with CKD, with or without diabetes 1.
Summary of Recommendations
- Start with RASi (ACEi or ARB) for people with high blood pressure, CKD, and severely increased albuminuria
- Target blood pressure goal of less than 130/80 mmHg
- Add diuretics, calcium channel blockers, or other agents as needed to achieve blood pressure goal
- Monitor kidney function, electrolytes, and blood pressure regularly and adjust medications as needed.
From the Research
Treatment of Severe Hypertension in Kidney Disease
The treatment of severe hypertension in patients with kidney disease is crucial to prevent or slow the progression of renal damage. According to 2, international guidelines recommend lowering blood pressure (BP) to 140/90 mm Hg or less in patients with uncomplicated hypertension, and to 130/80 mm Hg or less for patients with diabetic or chronic renal disease.
Recommended Treatment
- Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) are recommended as a first-line antihypertensive approach in patients with chronic kidney disease, as they have beneficial effects on proteinuria and declining renal function 2, 3.
- The addition of diuretics and calcium channel antagonists to RAS inhibitor therapy is also considered a rational strategy to reduce BP and preserve renal function 2, 4.
- Non-dihydropyridine calcium channel blockers (CCBs) consistently reduce albuminuria and slow the decline in kidney function, while dihydropyridine CCBs should not be used as monotherapy in proteinuric CKD patients but always in combination with a RAAS blocker 3.
Benefits of ACE Inhibitors and ARBs
- ACE inhibitors effectively reduce systemic vascular resistance in patients with hypertension, heart failure, or chronic renal disease, and have long-term renoprotective effects in patients with diabetic and non-diabetic renal disease 5.
- ARBs have been shown to be effective in reducing BP and proteinuria in poorly controlled hypertensive patients, and may be used in combination with ACE inhibitors for added renal protection 6.
Lifestyle Modifications and Multiple Antihypertensive Medications
- Patients with established CKD and/or diabetes with albuminuria require lifestyle modifications and multiple antihypertensive medications to achieve a BP goal < 130/80 mmHg 3.
- Sodium restriction and diuretic therapy can improve therapeutic efficacy in patients with insufficient response to ACE inhibitors or ARBs 5.