Antihypertensive Medications for Chronic Kidney Disease
For patients with chronic kidney disease (CKD), an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) should be the first-line antihypertensive medication, particularly in those with albuminuria. 1
First-Line Therapy Based on Albuminuria Status
Non-diabetic CKD patients:
- With albuminuria 30-300 mg/24h: ACEi or ARB suggested 1
- With albuminuria >300 mg/24h: ACEi or ARB strongly recommended 1
Diabetic CKD patients:
- With albuminuria 30-300 mg/24h: ACEi or ARB suggested 1
- With albuminuria >300 mg/24h: ACEi or ARB strongly recommended 1
Blood Pressure Targets
Blood pressure targets vary based on albuminuria status:
- Non-diabetic CKD with albuminuria <30 mg/24h: <140/90 mmHg 1
- Non-diabetic CKD with albuminuria ≥30 mg/24h: <130/80 mmHg 1
- Diabetic CKD with albuminuria <30 mg/24h: <140/90 mmHg 1
- Diabetic CKD with albuminuria ≥30 mg/24h: <130/80 mmHg 1
The 2021 KDIGO guidelines now recommend a target systolic BP <120 mmHg (using standardized office BP measurement) based on cardiovascular and survival benefits, not just renoprotection 1.
Second-Line and Additional Therapies
When additional medications are needed to reach BP targets:
Dihydropyridine calcium channel blockers (CCBs) - effective and well-tolerated in CKD 2, 3
- Examples: Amlodipine (2.5-10 mg daily), Felodipine (2.5-10 mg daily)
- Note: Should not be used as monotherapy in proteinuric CKD but always in combination with a RAAS blocker 3
Diuretics - cornerstone in CKD management 2, 3
- For CKD stages 1-4: Thiazide diuretics are effective
- For CKD stage 5 (GFR <30 mL/min): Loop diuretics preferred over thiazides 2
- Furosemide (20-80 mg twice daily)
- Bumetanide (0.5-2 mg twice daily)
- Torsemide (5-10 mg once daily)
Beta-blockers - consider in patients with concomitant heart failure or coronary artery disease 2
- Carvedilol preferred in heart failure with reduced ejection fraction
Combination Therapy
Many CKD patients with BP significantly above target will require combinations of 2 or more antihypertensive drugs 1. The combination of an ACEi/ARB with a diuretic has shown superior antiproteinuric and BP-lowering effects compared to ACEi/ARB monotherapy 4.
Important Considerations and Monitoring
- Avoid dual RAAS blockade (combination of ACEi, ARB, and direct renin inhibitors) due to safety concerns 2
- Monitor serum creatinine and potassium within 2-4 weeks of initiating or increasing doses of ACEi/ARB 2
- Discontinue ACEi/ARB if creatinine rises >30% within 4 weeks or if uncontrolled hyperkalemia occurs 2, 5
- Consider sodium restriction to enhance efficacy of ACEi/ARB and reduce adverse effects 5
- For resistant hypertension: Consider adding spironolactone with careful potassium monitoring 6
- For CKD stage 4 with uncontrolled hypertension: Chlorthalidone has shown effectiveness 6
Special Populations
- Kidney transplant recipients: Target BP <130/80 mmHg, with medication choice considering time after transplantation, calcineurin inhibitor use, albuminuria, and comorbidities 1
- Children with CKD: Start BP-lowering treatment when BP is consistently above 90th percentile for age, sex, and height 1
- Elderly CKD patients: Use caution due to higher risk for orthostatic hypotension 2
By following these evidence-based recommendations, clinicians can effectively manage hypertension in CKD patients while providing renoprotection and reducing cardiovascular risk.