What is the ideal prescription with dose for a patient with Chronic Kidney Disease (CKD) and hypertension?

Ideal Prescription for Chronic Kidney Disease with Hypertension

For patients with CKD and hypertension, the ideal first-line prescription is an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) titrated to the maximum tolerated dose, with a target blood pressure of <130/80 mmHg.

First-Line Therapy

ACEi/ARB Selection

• First choice: Lisinopril (ACEi)

  • Starting dose: 10 mg once daily (reduce to 5 mg if patient is on diuretics)
  • Target dose: 20-40 mg once daily 1
  • Dose adjustment for renal impairment:
    • eGFR >30 mL/min: No adjustment needed
    • eGFR 10-30 mL/min: Start with 2.5-5 mg once daily, titrate up as tolerated 2
    • eGFR <10 mL/min: Start with 2.5 mg once daily 2

• Alternative (if ACEi not tolerated): ARB options

  • Losartan: 25-50 mg daily, target 50-100 mg daily
  • Irbesartan: 150 mg daily, target 300 mg daily
  • Valsartan: 80-160 mg daily, target 160-320 mg daily 1

Monitoring After Initiation

1. Check serum creatinine, potassium, and blood pressure within 2-4 weeks of starting or increasing dose 1
2. Continue therapy unless:
   • Serum creatinine rises >30% within 4 weeks
   • Symptomatic hypotension develops
   • Uncontrolled hyperkalemia persists despite treatment 1

Add-On Therapy (if BP remains ≥130/80 mmHg)

For Patients with Diabetes or Albuminuria ≥200 mg/g

1. Add SGLT2 inhibitor if eGFR ≥20 mL/min/1.73m² 1

For All CKD Patients with Uncontrolled BP

1. Add dihydropyridine calcium channel blocker (e.g., amlodipine 5-10 mg daily) 1, 3
2. Add thiazide or thiazide-like diuretic if further BP control needed:
   • Chlorthalidone preferred (12.5-25 mg daily) for eGFR >30 mL/min/1.73m²
   • Loop diuretic (e.g., furosemide 20-80 mg twice daily) for eGFR <30 mL/min/1.73m² 1, 4

For Resistant Hypertension

• Consider adding nonsteroidal mineralocorticoid receptor antagonist (e.g., finerenone) if eGFR >25 mL/min/1.73m² and normal potassium 1

Special Considerations

Hyperkalemia Management

• If hyperkalemia develops, consider:
  • Dietary potassium restriction
  • Potassium binders if needed
  • Maintain RASi therapy if possible 1, 3

Albuminuria

• ACEi/ARB is strongly recommended for:
  • Severely increased albuminuria (A3) without diabetes (strong recommendation)
  • Moderately increased albuminuria (A2) without diabetes (conditional recommendation)
  • Moderately to severely increased albuminuria (A2-A3) with diabetes (strong recommendation) 1

Important Cautions

1. Never combine ACEi with ARB or direct renin inhibitor - this combination increases adverse effects without additional benefit 1
2. Avoid RASi in pregnancy - discontinue if pregnancy is planned or detected 1
3. Monitor closely in elderly patients - they may be more susceptible to hypotension 1
4. Continue ACEi/ARB even when eGFR falls below 30 mL/min/1.73m² unless contraindicated 1
5. Use standardized office BP measurement to accurately assess target achievement 1

Following this algorithm will optimize outcomes by reducing proteinuria, slowing CKD progression, and decreasing cardiovascular risk in patients with CKD and hypertension.