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

First-Line Hypertension Treatment in Patients with Chronic Kidney Disease

Angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) are the first-line treatment for hypertension in patients with chronic kidney disease, particularly in those with albuminuria. 1, 2

Treatment Selection Algorithm

• For patients with CKD and albuminuria (especially ≥300 mg/g creatinine), ACEi or ARB should be used as first-line therapy 2
• For black patients with CKD, initial therapy may include a thiazide-type diuretic or calcium channel blocker (CCB), with an ACEi or ARB added if the patient has proteinuria 2
• For non-black patients with CKD, initial therapy can include an ACEi, ARB, thiazide-type diuretic, or CCB 2
• All patients with CKD should ultimately be taking an ACEi or ARB, even if it is not the initial agent, unless contraindicated 2

Medication Selection Based on Patient Characteristics

• For patients with CKD and severely increased albuminuria:

  • ACEi or ARB is strongly recommended as first-line therapy 2, 1
  • These medications should be administered at the highest approved dose that is tolerated 2

• For patients with CKD without albuminuria:

  • ACEi or ARB may still be reasonable first-line options 2, 1
  • Dihydropyridine CCBs or thiazide diuretics are acceptable alternatives 1, 3

• For kidney transplant recipients:

  • Dihydropyridine CCB or ARB is recommended as first-line therapy 2

Blood Pressure Targets

• Current guidelines recommend a BP target of <130/80 mmHg for patients with CKD 2
• This is a change from older guidelines that recommended <140/90 mmHg 2
• For elderly patients (>60 years) with CKD, the same BP targets apply if well-tolerated 1

Monitoring and Precautions

• Check serum creatinine and potassium within 2-4 weeks of initiating or increasing the dose of an ACEi or ARB 2, 1
• Continue ACEi or ARB unless serum creatinine rises by more than 30% within 4 weeks of initiation or dose increase 2, 1
• Consider reducing the dose or discontinuing ACEi or ARB in cases of:
  • Symptomatic hypotension
  • Uncontrolled hyperkalemia despite treatment
  • Advanced kidney failure (eGFR <15 ml/min/1.73 m²) to reduce uremic symptoms 2, 1

Management of Resistant Hypertension

• For resistant hypertension, adding a mineralocorticoid receptor antagonist (MRA) like spironolactone can be effective 1, 3
• However, MRAs may cause hyperkalemia or reversible decline in kidney function, particularly in patients with low eGFR 2, 1
• Chlorthalidone (a thiazide-like diuretic) is effective in stage 4 CKD with uncontrolled hypertension 3

Important Contraindications and Cautions

• Avoid any combination of ACEi, ARB, and direct renin inhibitor therapy in patients with CKD 2, 1
• ACEi and ARBs are contraindicated during pregnancy 1
• Use with caution in patients with peripheral vascular disease due to association with renovascular disease 1

Special Considerations

• Hyperkalemia associated with ACEi/ARB use can often be managed by measures to reduce serum potassium rather than decreasing the dose or stopping the medication 2, 1
• In patients with TSC (tuberous sclerosis complex) and CKD, ACEi or ARB is also recommended as first-line therapy for hypertension 2
• For diabetic patients with CKD, ACEi or ARB is particularly beneficial 2