Hypertension Control in CKD Stage 4
For patients with CKD stage 4, an ACE inhibitor or ARB should be used as first-line therapy for hypertension control, typically combined with a loop diuretic, targeting a blood pressure of <140/90 mmHg. 1
Blood Pressure Targets
- The most recent KDIGO 2021 guidelines recommend a target blood pressure of <140/90 mmHg for most CKD patients 2
- For patients with albuminuria (>30 mg/24h), a lower target of <130/80 mmHg may be considered 1
- Earlier guidelines (2007 KDOQI) had recommended more aggressive targets (<130/80 mmHg) for all CKD patients, but more recent evidence has modified this approach 2
First-Line Medication Selection
ACE inhibitors or ARBs
- Strongly recommended (1B evidence) for CKD patients with albuminuria >300 mg/24h 2
- Should be titrated to the highest tolerated dose to maximize benefits 2
- Dosing examples:
- Benazepril: Start 10 mg daily, target 20-40 mg/day in 1-2 divided doses
- Captopril: Start 6.25-25 mg three times daily, target 25-150 mg 2-3 times daily
- Enalapril: Start 5 mg daily, target 10-40 mg daily in 1-2 divided doses 2
Monitoring after starting RAS inhibitors
- Check serum creatinine and potassium within 2-4 weeks of initiation or dose increase 2
- Continue therapy unless serum creatinine rises by more than 30% within 4 weeks 2
- Consider dose reduction or discontinuation only if:
- Symptomatic hypotension develops
- Uncontrolled hyperkalemia persists despite treatment
- Uremic symptoms worsen in very advanced CKD 2
Second-Line Therapy
Loop Diuretics
- Preferred over thiazides in CKD stage 4 due to better efficacy at lower GFR 1
- Options include:
- Furosemide: 20-80 mg twice daily
- Torsemide: 5-10 mg once daily
- Bumetanide: 0.5-2 mg twice daily 1
Chlorthalidone
- Recent evidence from the CLICK trial (2021) shows chlorthalidone is effective in stage 4 CKD with uncontrolled hypertension 3
- Starting dose 12.5 mg daily, can be titrated up to 50 mg daily if needed 3
- Reduced 24-hour systolic blood pressure by 11 mmHg compared to placebo and reduced albuminuria by 50% 3
Calcium Channel Blockers
- Long-acting dihydropyridine CCBs (amlodipine, felodipine) are effective second or third-line agents 1
- Non-dihydropyridine CCBs can reduce albuminuria but should not be used as monotherapy 4
Special Considerations
Combination Therapy
- Most CKD stage 4 patients will require multiple medications to achieve target BP 1
- Avoid combining ACE inhibitors, ARBs, and direct renin inhibitors - this combination increases adverse events without additional benefit (1B recommendation) 2
Hyperkalemia Management
- Hyperkalemia with RAS inhibitors should be managed with dietary potassium restriction and potassium-lowering medications rather than immediately discontinuing the RAS inhibitor 2
Volume Management
- Sodium restriction is critical for BP control in CKD stage 4 5
- Loop diuretics are often necessary for effective volume management 1
Resistant Hypertension
- Consider mineralocorticoid receptor antagonists (spironolactone) for resistant hypertension, but monitor potassium levels closely 2, 5
- Chlorthalidone may be an alternative for resistant hypertension in CKD stage 4 3
Monitoring Approach
- Regular monitoring of serum creatinine, potassium, and blood pressure is essential
- Consider home BP monitoring to guide therapy adjustments 6
- Reassess medication efficacy and side effects at each visit
By following this approach to hypertension management in CKD stage 4, you can effectively control blood pressure while balancing the risks of medication side effects and disease progression.