What is the recommended initial treatment for lowering blood pressure in a patient with stage 2 Chronic Kidney Disease (CKD) and newly diagnosed Hypertension?

Management of Hypertension in Stage 2 CKD

For a 54-year-old female with stage 2 CKD and newly diagnosed hypertension (average BP 136/88 mmHg), an ACE inhibitor such as lisinopril is recommended as first-line therapy based on the 2017 multi-organization guideline for hypertension management.

Assessment of Current Status

• Patient has stage 2 CKD with stable serum creatinine
• Newly diagnosed hypertension with average BP of 136/88 mmHg
• Normal serum potassium (4.5 mEq/L)
• 10-year ASCVD risk of 5.7%

Treatment Rationale

First-Line Therapy Selection

ACE inhibitors are preferred in CKD patients due to their:

1. Renoprotective effects beyond BP lowering 1
2. Ability to reduce albuminuria and slow CKD progression 1
3. Cardiovascular protective benefits in CKD patients 1

The KDIGO guidelines specifically recommend ACE inhibitors or ARBs as first-line agents in non-diabetic adults with CKD 1. While the patient's albuminuria status is not provided, ACE inhibitors are beneficial regardless of albuminuria level in CKD patients.

Why Not Other Options?

• Lisinopril plus hydrochlorothiazide: While combination therapy is often needed for BP control, it's generally recommended to start with monotherapy and add a second agent if needed 2
• Amlodipine: While effective for BP lowering, calcium channel blockers don't offer the same renoprotective benefits as ACE inhibitors in CKD patients 1
• Candesartan: An ARB would be an acceptable alternative if the patient develops ACE inhibitor-induced cough, but ACE inhibitors are typically tried first 1
• Diet and exercise alone: While lifestyle modifications are important, pharmacological therapy is indicated for this patient with established hypertension and CKD 2

Treatment Implementation

1. Start lisinopril at 10 mg daily 3

   • Lower starting dose (5 mg) may be considered if concerned about hypotension
   • Titrate up to 20-40 mg daily based on BP response

2. Concurrent lifestyle modifications:

   • Sodium restriction (<2 g sodium per day) 1
   • Regular physical activity (at least 150 minutes per week of moderate-intensity exercise) 1
   • Weight management if overweight/obese
   • DASH diet pattern

Monitoring Plan

1. Check serum creatinine and potassium 2-4 weeks after starting therapy
2. Monitor BP regularly (home and office measurements)
3. If BP target not achieved with maximum tolerated dose of lisinopril:
   • Add a thiazide diuretic (e.g., hydrochlorothiazide 12.5-25 mg daily) 3
   • Consider adding a calcium channel blocker if needed as third agent

BP Target

The target BP for this patient should be <140/90 mmHg initially, with consideration of a lower target of <130/80 mmHg if tolerated 1.

Important Considerations

• Monitor for potential adverse effects of ACE inhibitors:

  • Hyperkalemia (especially important in CKD)
  • Acute decline in GFR (>30% increase in serum creatinine may warrant dose reduction)
  • Cough (may require switching to an ARB)
  • Angioedema (rare but serious)

• Avoid concurrent use of NSAIDs which can reduce the efficacy of ACE inhibitors and potentially worsen kidney function

• Reassess cardiovascular risk factors regularly and consider additional interventions (e.g., statins) if indicated