What is the treatment for hypertension in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD)?

Treatment of Hypertension in CKD and ESRD

In patients with CKD and ESRD, blood pressure should be treated to a goal of less than 130/80 mmHg, with ACE inhibitors or ARBs as first-line therapy for those with albuminuria, and calcium channel blockers preferred after kidney transplantation. 1

Blood Pressure Targets

• For patients with CKD (all stages): Target BP < 130/80 mmHg 1
• For kidney transplant recipients: Target BP < 130/80 mmHg 1
• For patients with moderate-to-severe CKD with eGFR >30 mL/min/1.73m², target systolic BP to 120-129 mmHg if tolerated 1

Treatment Algorithm for CKD Patients

First-line therapy:

• For patients with albuminuria ≥300 mg/d or ≥300 mg/g creatinine ratio:
  • ACE inhibitor (Class IIa recommendation) 1
  • If ACE inhibitor not tolerated: ARB (Class IIb recommendation) 1

Second-line therapy (if BP goal not achieved):

• Long-acting dihydropyridine calcium channel blockers 2, 3
• Thiazide-type diuretics (for eGFR ≥30 mL/min/1.73m²) 3
• Loop diuretics (for eGFR <30 mL/min/1.73m²) 3

Third-line therapy (resistant hypertension):

• Mineralocorticoid receptor antagonists (spironolactone) with careful monitoring of potassium 3
• Chlorthalidone has shown efficacy even in stage 4 CKD 3

Special Considerations for ESRD/Dialysis Patients

Hypertension management in ESRD requires a different approach due to the loss of kidney function:

• Volume control is paramount:

  • Optimize ultrafiltration during dialysis 4
  • Strict sodium restriction (limit dietary intake) 4

• Medication considerations:

  • ACE inhibitors and ARBs can still be used but require careful monitoring 5
  • ARBs may be preferred over ACE inhibitors in ESRD patients on dialysis due to:
    • ACE inhibitors are variably dialyzed (requiring complex dosing) 5
    • ARBs are not dialyzable (simpler dosing) 5
    • ARBs have fewer side effects (no anaphylactoid dialyzer reactions) 5
  • Calcium channel blockers are effective and well-tolerated 4
  • Beta-blockers may be used for concurrent cardiovascular indications 4

Post-Kidney Transplantation Hypertension

• Target BP < 130/80 mmHg 1
• Calcium channel antagonists are recommended as first-line therapy based on improved GFR and kidney survival outcomes 1
• Avoid medications that may interact with immunosuppressants

Important Caveats and Pitfalls

• Monitoring for adverse effects:

  • Check electrolytes and kidney function within 2-4 weeks after initiating or changing doses of ACE inhibitors or ARBs 1
  • Monitor for hyperkalemia, especially when combining RAS blockers with mineralocorticoid receptor antagonists 3

• Medication adjustments during illness:

  • Instruct patients to temporarily hold ACE inhibitors/ARBs during episodes of volume depletion (vomiting, diarrhea) to prevent acute kidney injury 1

• Avoid certain combinations:

  • Do not use ACE inhibitors and ARBs together (increased risk of adverse events without additional benefit)
  • Non-dihydropyridine CCBs (verapamil, diltiazem) should be used cautiously in patients with heart failure 1

• Diuretic selection based on kidney function:

  • Thiazide-like diuretics (chlorthalidone) may remain effective even in advanced CKD 3
  • Switch to loop diuretics when eGFR falls below 30 mL/min/1.73m²

By following this structured approach to hypertension management in CKD and ESRD patients, clinicians can effectively reduce cardiovascular risk and potentially slow the progression of kidney disease.