What is the recommended treatment for a patient with newly diagnosed Chronic Kidney Disease (CKD) and Hypertension?

Treatment for Newly Diagnosed CKD with Hypertension

For patients with newly diagnosed chronic kidney disease (CKD) and hypertension, an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) should be the first-line therapy, with the addition of an SGLT2 inhibitor in appropriate patients. 1

First-Line Treatment Algorithm

Step 1: RAS Inhibitor (ACEi or ARB)

• Start with an ACEi as first-line therapy for all CKD patients with hypertension 1
• Titrate to the highest approved dose that is tolerated 1
• If ACEi not tolerated (e.g., due to cough), switch to an ARB 1
• Target BP: <130/80 mmHg 1, 2

Step 2: Add SGLT2 Inhibitor for Specific Patients

• Add SGLT2i for patients with:
  • Type 2 diabetes and eGFR ≥20 ml/min/1.73 m² 1
  • eGFR ≥20 ml/min/1.73 m² with urine ACR ≥200 mg/g 1
  • Heart failure, regardless of albuminuria level 1
  • Consider for eGFR 20-45 ml/min/1.73 m² with urine ACR <200 mg/g 1

Step 3: Additional Agents if BP Target Not Achieved

• Add dihydropyridine calcium channel blocker 1, 3
• Add thiazide or thiazide-like diuretic 1, 3
• Consider nonsteroidal MRA (e.g., finerenone) for patients with T2D, eGFR >25 ml/min/1.73 m², normal potassium, and persistent albuminuria despite maximum RASi dose 1

Monitoring Protocol

1. Initial Follow-up: Check BP, serum creatinine, and potassium within 2-4 weeks of starting or increasing RASi dose 1, 2

2. Continue RASi Unless:

   • Serum creatinine rises >30% within 4 weeks of initiation 1
   • Symptomatic hypotension develops 1
   • Uncontrolled hyperkalemia persists despite treatment 1

3. For Patients on SGLT2i:

   • Monitor kidney function but note that initial reversible eGFR decrease is expected and not a reason to discontinue 1
   • Withhold during prolonged fasting, surgery, or critical illness 1

4. For Patients on Nonsteroidal MRA (if prescribed):

   • Monitor potassium at 1 month after initiation and then every 4 months 1
   • Hold if K+ >5.5 mmol/l; consider restarting at lower dose when K+ ≤5.0 mmol/l 1

Important Clinical Considerations

• Avoid combination of ACEi, ARB, and direct renin inhibitors as this increases adverse effects without additional benefit 1

• Hyperkalemia management: Often can be managed with dietary modifications and potassium binders rather than decreasing or stopping RASi 1, 4

• Continue RASi even when eGFR falls below 30 ml/min/1.73 m² unless contraindicated 1, 2

• Dietary sodium restriction improves BP control and enhances efficacy of RAS inhibitors 5, 4

• Accurate BP measurement is essential for proper management; consider 24-hour ambulatory or home BP monitoring in CKD patients who may have masked hypertension or abnormal dipping patterns 5, 6

• Albuminuria level should guide treatment intensity, with stronger recommendations for RASi in patients with higher levels of albuminuria 1

By following this algorithm, you can optimize treatment for CKD patients with hypertension, reducing both kidney disease progression and cardiovascular risk.