What is the recommended treatment for Hypertension (HTN) with Chronic Kidney Disease (CKD)?

Treatment of Hypertension in Chronic Kidney Disease

Renin-angiotensin system inhibitors (ACEi or ARB) should be the first-line treatment for hypertension in patients with CKD, especially those with albuminuria, with a target systolic blood pressure of <120 mmHg when tolerated. 1

Blood Pressure Targets

• Target systolic blood pressure (SBP) should be <120 mmHg when tolerated, using standardized office BP measurement 1
• This target is based on cardiovascular and survival benefits shown in clinical trials, though there is no evidence for renoprotective effects at this level 1
• BP measurements should be standardized for accurate assessment, as applying the <120 mmHg target to non-standardized measurements could be hazardous 1
• Less intensive BP-lowering therapy may be appropriate for patients with very limited life expectancy or symptomatic postural hypotension 1

First-Line Pharmacological Treatment

• For patients with high BP, CKD, and severely increased albuminuria (G1-G4, A3) without diabetes: ACEi or ARB (strong recommendation) 1
• For patients with high BP, CKD, and moderately increased albuminuria (G1-G4, A2) without diabetes: ACEi or ARB (suggested) 1
• For patients with high BP, CKD, and moderately-to-severely increased albuminuria (G1-G4, A2 and A3) with diabetes: ACEi or ARB (strong recommendation) 1
• For patients with high BP, CKD, and no albuminuria, with or without diabetes: ACEi or ARB may still be reasonable 1, 2
• Losartan is specifically indicated for treatment of diabetic nephropathy with elevated serum creatinine and proteinuria in patients with type 2 diabetes and hypertension 3

Monitoring and Dose Adjustments

• ACEi or ARB should be administered at the highest approved dose that is tolerated 1
• Check BP, serum creatinine, and serum potassium within 2-4 weeks of initiation or dose increase 1
• Continue ACEi or ARB unless serum creatinine rises by more than 30% within 4 weeks following initiation or dose increase 1
• Hyperkalemia associated with RASi use can often be managed by measures to reduce serum potassium levels rather than decreasing the dose or stopping RASi 1
• Consider reducing the dose or discontinuing ACEi or ARB in cases of symptomatic hypotension, uncontrolled hyperkalemia despite treatment, or to reduce uremic symptoms in advanced kidney failure (eGFR <15 ml/min/1.73 m²) 1

Important Contraindications and Combinations to Avoid

• Avoid any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy in patients with CKD, with or without diabetes 1, 2
• DASH-type diet or potassium-rich salt substitutes may not be appropriate for patients with advanced CKD or impaired potassium excretion due to hyperkalemia risk 1
• Dietary sodium restriction is usually not appropriate for patients with sodium-wasting nephropathy 1

Additional Pharmacological Options

• For resistant hypertension, mineralocorticoid receptor antagonists are effective but may cause hyperkalemia or reversible decline in kidney function, particularly in patients with low eGFR 1, 2
• For kidney transplant recipients, a dihydropyridine calcium channel blocker (CCB) or an ARB is recommended as first-line therapy 1, 2
• In black patients, initial antihypertensive treatment should include a diuretic or a CCB, either alone or in combination with a RASi 2
• Dihydropyridine CCBs and diuretics (loop diuretics if eGFR <30 ml/min/1.73m²) are reasonable second and third-line options 1, 4

Non-Pharmacological Interventions

• Target sodium intake <2 g of sodium per day (or <5 g of sodium chloride per day) 1
• Advise moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 1
• Consider cardiorespiratory fitness status, physical limitations, cognitive function, and risk of falls when recommending physical activity 1
• Even physical activity below target levels may provide important health benefits 1

Treatment Algorithm

1. Start with ACEi or ARB, particularly if albuminuria is present 1, 2
2. If additional BP lowering needed: Add dihydropyridine CCB or thiazide/thiazide-like diuretic 2, 4
3. For resistant hypertension: Consider adding mineralocorticoid receptor antagonist with close monitoring of potassium and renal function 1, 2
4. For black patients: Consider starting with CCB or diuretic, then add RASi if needed 2
5. For kidney transplant recipients: Start with dihydropyridine CCB or ARB 1, 2

Monitoring and Follow-up

• Out-of-office BP measurements with ambulatory BP monitoring or home BP monitoring should complement standardized office BP readings 1
• Monitor eGFR, albuminuria, and blood electrolytes regularly 1
• Newer agents such as SGLT2 inhibitors may provide additional benefits beyond BP control in CKD patients with diabetes 5, 6