What are good anti-hypertensive medications for patients with Chronic Kidney Disease (CKD) stage 5?

Antihypertensive Medications for CKD Stage 5

For patients with CKD stage 5, loop diuretics are the preferred diuretic class, combined with either ACE inhibitors or ARBs (if tolerated), and calcium channel blockers as the optimal antihypertensive regimen. 1, 2

First-Line Medications

Loop Diuretics

• Loop diuretics (furosemide, bumetanide, torsemide) are preferred over thiazides in CKD stage 5 1
• Dosing recommendations:
  • Furosemide: 20-80 mg twice daily
  • Bumetanide: 0.5-2 mg twice daily
  • Torsemide: 5-10 mg once daily

Renin-Angiotensin System (RAS) Blockers

• ACE inhibitors or ARBs should be used with caution in CKD stage 5 1, 2
• Monitor for:
  • Hyperkalemia (increased risk in advanced CKD)
  • Acute kidney injury (especially with bilateral renal artery stenosis)
  • Creatinine increases >30% within 4 weeks (indication to discontinue) 2
• Use the lowest effective dose that controls blood pressure without worsening symptoms 2
• Check renal function and potassium within 2-4 weeks of initiation 2

Calcium Channel Blockers (CCBs)

• Dihydropyridine CCBs (amlodipine, felodipine) are effective and well-tolerated in CKD stage 5 1, 2
• Long-acting dihydropyridine CCBs are preferred for patients with orthostatic hypotension 2
• Dosing:
  • Amlodipine: 2.5-10 mg once daily
  • Felodipine: 2.5-10 mg once daily

Second-Line Medications

Mineralocorticoid Receptor Antagonists (MRAs)

• Can be effective for resistant hypertension in CKD stage 5 2, 3
• Requires extremely careful potassium monitoring due to high risk of hyperkalemia 2
• Consider only when other options have failed and with close monitoring

Beta-Blockers

• Consider in patients with concomitant heart failure or coronary artery disease 1
• Carvedilol is preferred in patients with heart failure with reduced ejection fraction 1
• Metoprolol succinate is also appropriate for heart failure patients 1

Medication Algorithm for CKD Stage 5

1. Start with a loop diuretic for volume control (essential in advanced CKD)

   • Furosemide 20-40 mg twice daily, titrate as needed
   • Monitor for electrolyte abnormalities

2. Add a calcium channel blocker (if no contraindications)

   • Amlodipine 5-10 mg daily
   • Monitor for peripheral edema

3. Consider adding an ACE inhibitor or ARB at low dose if:

   • Patient has significant albuminuria
   • No history of hyperkalemia
   • Stable kidney function
   • Monitor potassium and creatinine closely

4. For resistant hypertension:

   • Consider adding a beta-blocker (especially with cardiac indications)
   • Consider MRAs only with very close monitoring of potassium

Special Considerations

Volume Management

• Volume control is critical in CKD stage 5 2, 4
• Sodium restriction (2-3 g/day) should be emphasized 2, 4
• Loop diuretics may need dose adjustments based on response 2

Monitoring Parameters

• Check orthostatic blood pressure measurements at each visit 2
• Monitor electrolytes (especially potassium) and kidney function regularly 2
• Target blood pressure should be individualized in CKD stage 5, with general goal <130/80 mmHg if tolerated 1, 2

Medication Pitfalls

• Avoid thiazide diuretics in CKD stage 5 (ineffective at GFR <30 ml/min) 1
• Avoid combination of ACE inhibitors and ARBs (increases adverse effects without additional benefit) 2
• Be cautious with RAS blockers due to risk of hyperkalemia and worsening kidney function 1, 2
• Monitor for orthostatic hypotension, especially in elderly patients 2

By following this structured approach to antihypertensive therapy in CKD stage 5, blood pressure control can be achieved while minimizing adverse effects and potentially slowing progression to dialysis dependence.