Initial Management of Hypertension in Kidney Disease
For patients with hypertension and chronic kidney disease (CKD), first-line therapy should be a renin-angiotensin system inhibitor (RASi) - either an ACE inhibitor or ARB - targeting a systolic blood pressure of <120 mmHg when tolerated. 1
Blood Pressure Targets
The 2021 KDIGO guidelines recommend:
- Target systolic BP <120 mmHg in adults with CKD when tolerated, using standardized office BP measurement 1
- This target applies to both diabetic and non-diabetic CKD patients
- Less intensive BP targets may be appropriate for patients with limited life expectancy or symptomatic postural hypotension 1
Initial Pharmacological Management Algorithm
Step 1: RASi as Foundation Therapy
- For CKD with severely increased albuminuria (A3) without diabetes: Start ACEi or ARB (Strong recommendation) 1
- For CKD with moderately increased albuminuria (A2) without diabetes: Start ACEi or ARB (Suggested) 1
- For CKD with moderately-to-severely increased albuminuria with diabetes: Start ACEi or ARB (Strong recommendation) 1
- For CKD without albuminuria: Consider ACEi or ARB regardless of diabetes status 1
Step 2: Dosing and Monitoring
- Use highest approved dose that is tolerated 1
- Check BP, serum creatinine, and potassium within 2-4 weeks of initiation or dose increase 1
- Continue therapy unless serum creatinine rises >30% within 4 weeks 1
Step 3: Additional Agents (if BP target not achieved)
- Add dihydropyridine calcium channel blocker (CCB) and/or diuretic 1
- For patients with eGFR >20 mL/min/1.73m², consider adding SGLT2 inhibitor (has modest BP-lowering properties) 1
Non-Pharmacological Approaches
Implement these concurrently with medication:
- Sodium restriction: Target <2g sodium per day (<5g salt) 1
- Exception: Not appropriate for patients with sodium-wasting nephropathy 1
- Physical activity: Moderate-intensity activity for at least 150 minutes weekly, adjusted to individual tolerance 1
- Diet: DASH-type diet (caution with advanced CKD due to hyperkalemia risk) 1
- Weight management: Achieve and maintain healthy BMI 2
Special Considerations in Acute Kidney Injury (AKI)
- Initial approach focuses on treating the underlying cause of AKI
- Avoid nephrotoxic agents
- Maintain adequate volume status
- Continue RASi with close monitoring unless:
Management of Resistant Hypertension
For patients not achieving BP targets despite three medications including a diuretic:
- Evaluate medication adherence
- Consider secondary causes of hypertension
- Consider adding a mineralocorticoid receptor antagonist (MRA) 1
- Non-steroidal MRAs may be preferred in CKD due to lower hyperkalemia risk 3
- Consider chlorthalidone for stage 4 CKD with uncontrolled hypertension 3
Monitoring and Follow-up
- Monitor BP regularly using standardized measurement techniques 1
- Consider out-of-office BP monitoring (home or ambulatory) to complement office readings 1
- Check serum creatinine and potassium within 2-4 weeks after starting RASi 1
- Adjust therapy based on BP response, kidney function, and electrolyte status
Common Pitfalls to Avoid
- Discontinuing RASi prematurely: Small increases in creatinine (<30%) after starting RASi are expected and not an indication to stop therapy 1
- Inadequate diuretic therapy: Patients with CKD often require higher doses or more potent diuretics 3
- Failure to address dietary sodium: Sodium restriction significantly enhances the efficacy of antihypertensive medications 3
- Inappropriate BP measurement: Non-standardized BP measurement can lead to inaccurate treatment decisions 1
- Underutilization of combination therapy: Most CKD patients require multiple agents to achieve BP targets 1
By following this structured approach to hypertension management in kidney disease, clinicians can optimize outcomes related to both kidney function preservation and cardiovascular risk reduction.