What are the recommended blood pressure medications for patients with impaired renal function?

Blood Pressure Medications for Renal Failure

Renin-angiotensin system inhibitors (ACEi or ARB) are the first-line antihypertensive medications for patients with chronic kidney disease, particularly those with albuminuria. These medications should be used at the highest tolerated dose to achieve optimal benefits for blood pressure control and renal protection 1.

First-Line Therapy

ACE Inhibitors or ARBs

• Strongly recommended for CKD patients with:
  • Severely increased albuminuria (>300 mg/24h) without diabetes (1B evidence) 1
  • Moderately increased albuminuria (30-300 mg/24h) without diabetes (2C evidence) 1
  • Moderately-to-severely increased albuminuria with diabetes (1B evidence) 1
• May be reasonable for CKD patients with no albuminuria, with or without diabetes 1
• Dosing considerations:
  • Use highest approved dose that is tolerated 1
  • Dose reduction required in advanced renal failure for most ACEi (except fosinopril) 2, 3
  • Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1
  • Continue therapy unless serum creatinine rises >30% within 4 weeks 1, 4

Second-Line and Add-On Therapy

Diuretics

• Thiazide or thiazide-like diuretics: Effective even in advanced CKD 5
• Loop diuretics: Preferred for patients with eGFR <30 ml/min/1.73m² or volume overload 5
• Useful for managing resistant edema in combination with other agents 1
• Monitor for adverse effects:
  • Hypokalemia with thiazide and loop diuretics
  • Hyponatremia with thiazide diuretics
  • Volume depletion (especially in elderly patients) 1

Calcium Channel Blockers (CCBs)

• Dihydropyridine CCBs: Recommended as first-line agents in kidney transplant recipients 1
• Effective add-on therapy for CKD patients not at target BP with RASi alone 5

Mineralocorticoid Receptor Antagonists (MRAs)

• Effective for management of refractory hypertension 1
• Use with caution due to risk of hyperkalemia, especially in advanced CKD 1
• Monitor potassium levels closely when combined with RASi 1

Blood Pressure Targets

• Target systolic BP <120 mmHg when tolerated, using standardized office BP measurement 1
• Less intensive BP targets may be appropriate for patients with:
  • Very limited life expectancy
  • Symptomatic postural hypotension 1

Important Monitoring and Precautions

1. Monitor serum creatinine and potassium:

   • Check within 2-4 weeks after initiation or dose increase of RASi 1
   • Continue RASi unless creatinine rises >30% or uncontrolled hyperkalemia develops 1

2. Consider reducing dose or discontinuing RASi in cases of:

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

3. Avoid combinations of:

   • ACEi + ARB
   • ACEi or ARB + direct renin inhibitor 1
   • These combinations increase risk of hyperkalemia and AKI without additional benefit

4. Counsel patients to:

   • Hold RASi and diuretics when at risk for volume depletion 1
   • Temporarily stop RASi during "sick days" 1

Lifestyle Modifications

• Sodium restriction: <2g sodium per day (<5g sodium chloride) 1
• Physical activity: At least 150 minutes per week of moderate-intensity activity 1

Special Considerations

• For kidney transplant recipients: Target BP <130/80 mmHg using dihydropyridine CCBs or ARBs as first-line agents 5
• For children with CKD: Target 24-hour mean arterial pressure ≤50th percentile for age, sex, and height 5
• For patients with contrast-induced nephropathy risk: Hydration with 250-500 mL of sodium chloride 0.9% before and after procedures 1

The evidence from the SPRINT trial supports intensive BP control in non-diabetic CKD patients, showing a 25% reduction in cardiovascular events and 28% reduction in all-cause mortality with a target SBP <120 mmHg compared to <140 mmHg 1.