What are the best antihypertensive medications for patients with Chronic Kidney Disease (CKD)?

Best Antihypertensive Medications for Chronic Kidney Disease

Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are the first-line antihypertensive medications for patients with chronic kidney disease (CKD), especially those with albuminuria. 1

First-Line Therapy Based on Albuminuria Status

For CKD with Albuminuria:

• Severe albuminuria (>300 mg/24h) without diabetes: ACEIs or ARBs strongly recommended (1B) 1
• Moderate albuminuria (30-300 mg/24h) without diabetes: ACEIs or ARBs suggested (2C) 1
• Moderate to severe albuminuria with diabetes: ACEIs or ARBs strongly recommended (1B) 1

For CKD without Albuminuria:

• ACEIs or ARBs may still be reasonable first-line agents, though evidence is less strong 1

Dosing and Monitoring

• Use the highest tolerated dose of ACEIs or ARBs to achieve maximum benefit 1
• Monitor serum creatinine, potassium, and blood pressure within 2-4 weeks after initiation or dose increase 1
• Continue therapy unless serum creatinine rises by >30% within 4 weeks of starting treatment 1

Blood Pressure Targets

• Target BP for most CKD patients: <120 mmHg systolic when tolerated (2B) 1
• For non-diabetic CKD with albuminuria >300 mg/24h: <130/80 mmHg 1
• For diabetic CKD with albuminuria ≥30 mg/24h: <130/80 mmHg 1

Second-Line and Add-On Therapy

1. Diuretics: Particularly useful in CKD; often needed for volume control

   • Thiazide-like diuretics (chlorthalidone) can be effective even in advanced CKD (stage 4) 2
   • Loop diuretics may be needed as GFR declines

2. Calcium Channel Blockers (CCBs):

   • Dihydropyridine CCBs (e.g., amlodipine) should not be used as monotherapy in proteinuric CKD but are effective when combined with ACEIs/ARBs 3
   • For kidney transplant recipients: dihydropyridine CCBs or ARBs are recommended as first-line agents (1C) 1

3. Mineralocorticoid Receptor Antagonists (MRAs):

   • Effective for resistant hypertension but require careful monitoring due to hyperkalemia risk, especially in advanced CKD 1

Important Cautions

• Avoid combination of ACEIs, ARBs, and direct renin inhibitors as this increases adverse events without additional benefit (1B) 1
• Monitor for hyperkalemia, especially with ACEIs/ARBs and MRAs
• Consider reducing or discontinuing ACEIs/ARBs in cases of:
  • Symptomatic hypotension
  • Uncontrolled hyperkalemia despite treatment
  • eGFR <15 ml/min/1.73 m² with uremic symptoms 1

Special Populations

• Kidney transplant recipients: Target BP <130/80 mmHg; use dihydropyridine CCBs or ARBs as first-line agents 1
• Children with CKD: Use ACEIs or ARBs as first-line therapy; target 24-hour mean arterial pressure ≤50th percentile for age, sex, and height 1

Lifestyle Modifications

• Sodium restriction (<2g/day) 4
• Moderate-intensity physical activity (at least 150 minutes per week) 4

By following this approach to antihypertensive therapy in CKD, clinicians can help reduce proteinuria, slow CKD progression, and decrease cardiovascular risk in this high-risk population.