What is the treatment for hypertension in patients with Chronic Kidney Disease (CKD)?

Treatment of Hypertension in Chronic Kidney Disease (CKD)

For patients with chronic kidney disease, first-line treatment of hypertension should be a renin-angiotensin system inhibitor (ACE inhibitor or ARB), particularly in those with albuminuria, with target blood pressure individualized based on albuminuria status. 1

Blood Pressure Targets in CKD

Non-diabetic CKD patients:

• Without albuminuria (<30 mg/24h): Target BP <140/90 mmHg 1
• With moderate albuminuria (30-300 mg/24h): Target BP <130/80 mmHg 1
• With severe albuminuria (>300 mg/24h): Target BP <130/80 mmHg 1

Diabetic CKD patients:

• Without albuminuria (<30 mg/24h): Target BP <140/90 mmHg 1
• With albuminuria (≥30 mg/24h): Target BP <130/80 mmHg 1

Recent guidelines (2021):

• Target systolic BP <120 mmHg using standardized office measurement if tolerated 1
• For older patients (≥65 years): Target systolic BP 130-139 mmHg 1

First-Line Medication Selection

For patients with albuminuria:

• Severe albuminuria (>300 mg/24h): ACE inhibitor or ARB strongly recommended (1B evidence) 1
• Moderate albuminuria (30-300 mg/24h): ACE inhibitor or ARB suggested (2D evidence) 1

For patients without albuminuria:

• Multiple antihypertensive agents may be needed
• Consider comorbidities when selecting agents

Treatment Algorithm

1. Start with lifestyle modifications:

   • Sodium restriction (<2g sodium/day) 1
   • Regular physical activity (150 minutes/week of moderate intensity) 1
   • Weight management for overweight/obese patients 1
   • DASH diet 1
   • Limiting alcohol consumption 1

2. First-line pharmacotherapy:

   • ACE inhibitor or ARB for patients with albuminuria 1
   • Monitor for hyperkalemia and acute decline in kidney function
   • Continue unless serum creatinine rises by >30% within 4 weeks 2

3. Second-line agents (if BP target not achieved):

   • Dihydropyridine calcium channel blocker (CCB) 1
   • Thiazide or thiazide-like diuretic (use loop diuretics if eGFR <30 ml/min/1.73m²) 1

4. Third-line agents:

   • Mineralocorticoid receptor antagonists (spironolactone) for resistant hypertension 1, 3
   • Beta-blockers (particularly if coronary artery disease or heart failure) 1

5. For resistant hypertension:

   • Ensure proper BP measurement technique
   • Assess medication adherence
   • Consider chlorthalidone (effective even in stage 4 CKD) 3
   • Consider spironolactone (with careful monitoring of potassium) 1

Important Monitoring Considerations

• Regular BP monitoring using standardized measurement techniques 1
• Check for postural hypotension regularly when treating with BP-lowering drugs 1
• Monitor serum creatinine and potassium within 1-2 weeks of starting or increasing dose of ACE inhibitor/ARB 2
• Assess albuminuria regularly to guide treatment decisions 2
• Avoid combining ACE inhibitor, ARB, and direct renin inhibitor 1

Special Considerations

• Kidney transplant recipients: Consider dihydropyridine CCB or ARB as first-line therapy 1
• Black patients: Diuretics or CCBs may be more effective as initial therapy 1
• Elderly patients: More gradual BP reduction with careful monitoring for orthostatic hypotension 1
• Advanced CKD (G4-G5): Consider using loop diuretics instead of thiazides 1

Emerging Therapies

• SGLT2 inhibitors for patients with type 2 diabetes and CKD (eGFR ≥20 mL/min/1.73 m²) 2, 4
• Non-steroidal mineralocorticoid receptor antagonists (finerenone) if albuminuria persists despite ACE inhibitor/ARB therapy 2, 3

The treatment of hypertension in CKD requires careful consideration of albuminuria status, comorbidities, and potential adverse effects. Regular monitoring of BP, kidney function, and electrolytes is essential for optimizing outcomes and minimizing complications.