What is the management of hypertensive urgency in the setting of Chronic Kidney Disease (CKD) stage 3?

From the Guidelines

Hypertensive urgency in CKD stage 3 should be managed with prompt but controlled blood pressure reduction, aiming for a target blood pressure of <130/80 mmHg, using oral medications such as ACE inhibitors or ARBs, which provide renoprotection, as the first-line treatment. The management of hypertensive urgency in the setting of Chronic Kidney Disease (CKD) stage 3 requires careful consideration of the potential benefits and risks of blood pressure reduction, as evidenced by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

Key Considerations

• The presence of hypertension in CKD patients accelerates further kidney injury, making treatment crucial to prevent further kidney functional decline 1.
• The SPRINT study results support a lower target of <130/80 mmHg for all patients with CKD, including those with stage 3 to 4 CKD, as it provides the same benefits for reduction in the CVD composite primary outcome and all-cause mortality as seen in the full study cohort 1.
• ACE inhibitors or ARBs are preferred drugs for treatment of hypertension in CKD patients, especially if albuminuria is present, due to their renoprotective effects, although the evidence is mixed 1.
• The combination of an ACE inhibitor and an ARB should be avoided due to reported harms demonstrated in several large cardiology trials and in 1 diabetic nephropathy trial 1.

Management Approach

• Start with oral medications rather than IV agents, aiming to lower blood pressure by 20-25% within the first 24-48 hours, not immediately.
• First-line medications include ACE inhibitors or ARBs, such as lisinopril 2.5-5mg daily, which should be started at lower doses and titrated slowly while monitoring potassium and creatinine.
• Monitor blood pressure every 30-60 minutes initially, then every 4-6 hours as it stabilizes.
• Check renal function and electrolytes within 24-48 hours of treatment initiation, as aggressive BP lowering can worsen kidney function.
• Lifestyle modifications, including sodium restriction (<2g/day), weight management, and limiting alcohol and NSAIDs, are essential components of ongoing care.

From the Research

Management of Hypertensive Urgency in CKD Stage 3

• Hypertensive urgency in the setting of Chronic Kidney Disease (CKD) stage 3 is defined as a severe elevation in blood pressure without acute target organ damage 2.
• The management of hypertensive urgency in CKD stage 3 involves a gradual lowering of blood pressure over 24-48 hours with oral medication, avoiding aggressive blood pressure lowering 3, 4.
• The choice of specific antihypertensive drugs depends on the underlying causes of the crisis, patient demographics, cardiovascular risk, and comorbidities 3.
• For patients with CKD, the recommended blood pressure goal is <130/80 mmHg, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are recommended as first-line treatment 5.
• Non-dihydropyridine calcium channel blockers (CCBs) and diuretics may also be used in the management of hypertension in CKD patients, with dihydropyridine CCBs used in combination with a renin-angiotensin-aldosterone system (RAAS) blocker in proteinuric patients 5.

Considerations for CKD Stage 3

• Patients with CKD stage 3 are at increased risk of cardiovascular events and have a higher prevalence of left ventricle hypertrophy and carotid plaque 2.
• Hypertensive urgency in CKD stage 3 patients is associated with a higher risk of uncontrolled blood pressure and a worse cardiovascular risk profile 2.
• The management of hypertensive urgency in CKD stage 3 requires careful consideration of the patient's underlying kidney disease and cardiovascular risk factors 3, 4, 5.