What are the guidelines for blood pressure management in Chronic Kidney Disease (CKD)?

From the Guidelines

Blood pressure management in chronic kidney disease (CKD) should target a systolic blood pressure of <120 mmHg, if tolerated, for adults with moderate-to-severe CKD who are receiving BP-lowering drugs and who have eGFR >30 mL/min/1.73 m², as recommended by the 2024 ESC guidelines 1.

Key Considerations

• The target blood pressure may vary depending on individual patient characteristics, such as age, kidney function, and presence of proteinuria or other comorbidities.
• First-line treatment typically involves an angiotensin-converting enzyme inhibitor (ACE inhibitor) or an angiotensin receptor blocker (ARB), as these medications provide both blood pressure control and kidney protection by reducing proteinuria and intraglomerular pressure.
• Lifestyle modifications, including sodium restriction, regular physical activity, weight management, and limiting alcohol consumption, are crucial complementary strategies to slow disease progression and reduce cardiovascular risk.

Treatment Approach

• For patients with CKD, it is recommended to lower systolic blood pressure to a range of 130–139 mmHg, with individualized treatment considered according to its tolerability and impact on renal function and electrolytes 1.
• Renin–angiotensin system inhibitors, such as ACE inhibitors or ARBs, are recommended as the first-line treatment to achieve the target blood pressure, with the avoidance of any combination of ACEi, ARB, and direct renin-inhibitor therapy 1.
• Regular monitoring of serum creatinine, potassium, and estimated glomerular filtration rate is essential, particularly after starting ACE inhibitors or ARBs, as these can cause an initial decrease in kidney function and hyperkalemia.

Blood Pressure Measurement

• Standardized office blood pressure measurement is recommended, with out-of-office blood pressure measurements using home blood pressure monitoring or ambulatory blood pressure monitoring considered to complement office readings 1.
• Ambulatory blood pressure monitoring should be considered in patients with difficult-to-control blood pressure, left ventricular hypertrophy, proteinuria, or declining kidney function but normal office blood pressure readings.

From the Research

Blood Pressure Management Guidelines in CKD

The management of hypertension in patients with Chronic Kidney Disease (CKD) is crucial to prevent the progression of kidney disease and reduce cardiovascular risk. The following guidelines are based on recent studies:

• Achieving target blood pressures recommended by international guidelines is mandatory, and often demands a multiple-level management approach, including pharmacological and lifestyle measures 2.
• The target blood pressure in CKD patients is less than 130/80 mm Hg, or 125/75 mm Hg, if the amount of urinary protein is more than 1 g/day 3.
• The first-line agents for controlling blood pressure are inhibitors of the renin-angiotensin system (RAS): angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, which have been shown to have renoprotective effects in addition to their ability to control blood pressure 3.
• Other classes of antihypertensive agents, such as diuretics and calcium channel blockers, should be administered in addition to RAS inhibitors to achieve the target blood pressure 3.
• Emerging evidence suggests that novel agents, such as sodium glucose transporter 2 (SGLT2) inhibitors, non-steroidal mineralocorticoid receptor antagonists, and endothelin receptor antagonists, can retard the progression of kidney disease and reduce cardiovascular mortality on top of standard care treatment with RAS inhibitors 2, 4.
• Accurate blood pressure measurement is essential, and dietary sodium restriction can improve blood pressure control, especially among patients treated with an agent to block the RAS 5.
• For patients with treatment-resistant hypertension, the addition of spironolactone to the baseline antihypertensive regimen is recommended, but requires careful monitoring of blood pressure and kidney function to prevent adverse events 5.

Pharmacological Interventions

Pharmacological interventions play a crucial role in managing hypertension in CKD patients. The following are some of the key pharmacological interventions:

• Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers as first-line agents 3.
• Diuretics, such as thiazide-like diuretics, as alternative therapeutic options for patients with stage 4 CKD and uncontrolled hypertension 5.
• Calcium channel blockers as reasonable second- and third-line therapeutic options 5.
• Emerging agents, such as non-steroidal mineralocorticoid receptor antagonists, dual endothelin receptor antagonists, and aldosterone synthase inhibitors, offer novel targets and strategies to control blood pressure better 5.

Lifestyle Modifications

Lifestyle modifications are also essential in managing hypertension in CKD patients. The following are some of the key lifestyle modifications:

• Dietary sodium restriction to improve blood pressure control 5.
• Other lifestyle measures, such as weight loss, increased physical activity, and smoking cessation, can also help to control blood pressure and reduce cardiovascular risk 2.