What is the best antihypertensive for a patient with Chronic Kidney Disease (CKD) and an estimated Glomerular Filtration Rate (eGFR) of 30 or less?

Best Antihypertensive Medications in CKD with eGFR ≤30

For patients with CKD and eGFR ≤30 ml/min/1.73m², renin-angiotensin system inhibitors (RASi) such as ACEi or ARB should be the first-line antihypertensive therapy, and should be continued even when eGFR falls below 30 ml/min/1.73m². 1

First-Line Therapy: RASi (ACEi or ARB)

Indications and Benefits:

• Strongly recommended for CKD patients with albuminuria (moderate or severe)
• Continue even when eGFR falls below 30 ml/min/1.73m² 1
• Reduces proteinuria and slows CKD progression
• Provides cardiovascular protection

Dosing Considerations:

• For ACEi (e.g., lisinopril): Start with reduced dose in severe CKD
  • For eGFR 10-30 ml/min: Start with half the usual dose (2.5-5 mg daily) 2
  • For patients on hemodialysis or eGFR <10 ml/min: Start with 2.5 mg daily 2
• Titrate to highest tolerated dose as benefits were demonstrated at higher doses 1

Monitoring:

• Check serum creatinine, potassium, and BP within 2-4 weeks of initiation 1
• Continue therapy unless creatinine rises >30% within 4 weeks 1
• Manage hyperkalemia with dietary measures or potassium binders rather than discontinuing RASi 1

Second-Line Options

Loop Diuretics

• Preferred over thiazides in CKD with eGFR <30 ml/min/1.73m² 3
• Examples: furosemide, torsemide
• Essential for volume management in advanced CKD

SGLT2 Inhibitors

• Recommended for CKD patients with eGFR ≥20 ml/min/1.73m² 1
• Particularly beneficial if:
  • Patient has diabetes
  • Urine ACR ≥200 mg/g
  • Heart failure is present
• Can continue even if eGFR falls below 20 ml/min/1.73m² unless not tolerated 1

Nonsteroidal MRAs

• Consider for patients with eGFR >25 ml/min/1.73m², normal potassium, and persistent albuminuria despite RASi 1
• Careful monitoring of potassium is essential

Third-Line Options

Calcium Channel Blockers

• Dihydropyridine CCBs (amlodipine, felodipine) can be added for additional BP control 3
• Non-dihydropyridine CCBs should be used with caution in advanced CKD 4
• Should not be used as monotherapy in proteinuric CKD 4

Beta-Blockers

• Beneficial in patients with concurrent heart failure 3
• Carvedilol, bisoprolol, and metoprolol succinate are preferred options

Important Considerations

Hyperkalemia Management:

• Monitor potassium levels regularly
• Consider potassium binders rather than discontinuing RASi 1
• Dietary potassium restriction may be necessary

Avoid These Combinations:

• Do not combine ACEi with ARB or direct renin inhibitors 1
• This increases risk of hyperkalemia and acute kidney injury without additional benefit

When to Reduce Dose or Discontinue RASi:

• Symptomatic hypotension
• Uncontrolled hyperkalemia despite treatment
• To reduce uremic symptoms in kidney failure (eGFR <15 ml/min/1.73m²) 1

Blood Pressure Targets:

• Target BP <130/80 mmHg for CKD patients 3
• Monitor for hypotension, which may accelerate CKD progression 5

Special Caution

• Avoid glyburide in patients with eGFR <30 ml/min/1.73m² 1
• Monitor for hypotension which can worsen kidney function 5
• Consider reducing antihypertensive medications if chronic episodic hypotension occurs 5

By following this evidence-based approach, you can optimize blood pressure control while preserving kidney function and reducing cardiovascular risk in patients with advanced CKD.