What antihypertensive medication is recommended for patients with Chronic Kidney Disease (CKD) stage 5?

Antihypertensive Management in CKD Stage 5

Loop diuretics are the preferred first-line diuretic therapy for patients with CKD stage 5, combined with calcium channel blockers and cautious use of RAS inhibitors (ACEi/ARB) if tolerated. 1

First-Line Therapy Options

Loop Diuretics

• Preferred over thiazides in CKD stage 5 (GFR <30 mL/min) 2, 1
• Dosing recommendations:
  • Furosemide: 20-80 mg twice daily
  • Bumetanide: 0.5-2 mg twice daily
  • Torsemide: 5-10 mg once daily 1

Calcium Channel Blockers (CCBs)

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

RAS Inhibitors (ACEi/ARB)

• Use with extreme caution in CKD stage 5 due to risks of hyperkalemia and worsening kidney function 2, 1
• If used for albuminuria control:
  • Start with lowest effective dose
  • Monitor serum creatinine and potassium within 2-4 weeks of initiation 2
  • Discontinue if creatinine rises by >30% within 4 weeks 2, 1

Monitoring and Adjustment Protocol

1. Regular monitoring:

   • Check blood pressure, serum creatinine, and potassium within 2-4 weeks of medication initiation or dose increase 2
   • Assess for orthostatic hypotension at each visit 1

2. When to reduce or discontinue medications:

   • RAS inhibitors: If serum creatinine rises >30% within 4 weeks or uncontrolled hyperkalemia occurs 2, 1
   • Diuretics: If causing symptomatic hypotension 1

3. Blood pressure targets:

   • General goal: <130/80 mmHg using standardized office BP measurement 1
   • For CKD stage 5: Individualize targets based on tolerance 1

Special Considerations

• Avoid combination of ACEi, ARB, and direct renin inhibitors 2
• Beta-blockers (Carvedilol, Metoprolol succinate) should be considered in patients with concomitant heart failure or coronary artery disease 1
• Mineralocorticoid receptor antagonists may be considered for resistant hypertension but require careful potassium monitoring 2
• Thiazide diuretics are ineffective at GFR <30 mL/min and should be avoided in CKD stage 5 2, 1

Management of Hyperkalemia

• Hyperkalemia associated with RAS inhibitors should be managed with measures to reduce serum potassium rather than immediately discontinuing therapy 2
• Consider dietary potassium restriction, correction of metabolic acidosis, and potentially potassium binders 1

Orthostatic Hypotension Management

• Measure BP in both supine and standing positions 1
• Assess for symptoms of postural dizziness 1
• Non-pharmacological approaches: sodium restriction, gradual position changes, compression stockings, adequate hydration, and avoidance of large meals and alcohol 1
• Consider dose reduction or medication change if orthostatic symptoms worsen 1

By following this approach, you can effectively manage hypertension in CKD stage 5 patients while minimizing adverse effects and optimizing outcomes related to morbidity, mortality, and quality of life.