What antihypertensive (blood pressure lowering) medications are recommended for patients with Chronic Kidney Disease (CKD) and Congestive Heart Failure (CHF)?

Antihypertensive Medications for CKD and CHF

For patients with both chronic kidney disease (CKD) and congestive heart failure (CHF), angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) should be the first-line antihypertensive therapy, followed by diuretics, with additional agents added as needed for blood pressure control. 1

First-Line Therapy: ACEIs/ARBs

ACEIs and ARBs are strongly recommended as first-line therapy for several important reasons:

• They reduce mortality and morbidity in heart failure patients 2
• They slow kidney disease progression in CKD patients with albuminuria 2
• They improve cardiovascular outcomes in both conditions 1
• They reduce proteinuria, which is common in CKD 2

For patients with CKD and severely increased albuminuria (≥300 mg/g creatinine), ACEIs/ARBs have particularly strong evidence supporting their use 2.

Specific Medication Options:

• ACEIs: Lisinopril, enalapril, ramipril 3
• ARBs: Losartan, valsartan, candesartan (use when ACEIs are not tolerated) 4

Second-Line Therapy: Diuretics

Diuretics are essential for managing fluid overload in CHF and can be effective for blood pressure control in CKD:

• Loop diuretics (furosemide, torsemide): Preferred in symptomatic heart failure and moderate-to-severe CKD (GFR <30 mL/min) 2, 1
• Thiazide diuretics: Effective in mild-to-moderate CKD and CHF with systolic dysfunction 2
• Aldosterone antagonists (spironolactone, eplerenone): Beneficial in heart failure with reduced ejection fraction (HFrEF) but require careful monitoring for hyperkalemia, especially in advanced CKD 2, 5

Additional Therapy Options

When combination therapy is needed to reach blood pressure targets:

1. SGLT2 inhibitors (dapagliflozin, empagliflozin): Recommended for patients with HFrEF to reduce hospitalization and cardiovascular death, with benefits extending to patients with CKD stages 3 and 4 (eGFR >20 mL/min/1.73m²) 2, 6

2. Beta-blockers: Beneficial in HFrEF across all stages of CKD, including patients on dialysis 6

   • Preferred agents: Carvedilol, bisoprolol, metoprolol succinate 2
   • Caution: May be poorly tolerated in some patients with advanced cardiac amyloidosis 2

3. Dihydropyridine calcium channel blockers (amlodipine, felodipine): Can be added if needed for additional BP control 1

   • Avoid non-dihydropyridine CCBs (diltiazem, verapamil) in HFrEF 2

Blood Pressure Targets

• The 2021 KDIGO guideline recommends a systolic BP target of <120 mmHg for patients with CKD 2
• For patients with both CKD and CHF, a target of <130/80 mmHg is generally recommended 2, 1

Important Precautions

1. Avoid ACEi/ARB combination: This increases risk of hyperkalemia and acute kidney injury without additional benefit 2, 1

2. Monitor for adverse effects:

   • Check serum creatinine and potassium within 2-4 weeks of initiation or dose increase of ACEIs/ARBs 1
   • ACEIs/ARBs can be continued unless serum creatinine rises by more than 30% 2
   • Be vigilant for hyperkalemia, especially with aldosterone antagonists 2

3. Volume status: Avoid excessive diuresis leading to volume contraction and worsening renal function 6

Special Considerations

• For patients with advanced CKD (eGFR <30 mL/min), medication dosing may need adjustment 6
• Consider referral to nephrology when there is uncertainty about kidney disease etiology or for difficult management issues 2
• A multidisciplinary approach involving both cardiology and nephrology may improve outcomes 6

By following this evidence-based approach to antihypertensive therapy in patients with both CKD and CHF, clinicians can optimize outcomes while minimizing risks of adverse effects.