What is the initial treatment for hypertension in patients with chronic kidney disease (CKD)?

Initial Treatment for Hypertension in Patients with Chronic Kidney Disease (CKD)

Renin-angiotensin system inhibitors (RASi), specifically ACE inhibitors or ARBs, are recommended as first-line treatment for hypertension in patients with CKD, particularly those with albuminuria. 1

Blood Pressure Targets in CKD

• Adults with hypertension and CKD should be treated to a BP goal of less than 130/80 mm Hg 1
• For patients with moderate-to-severe CKD with eGFR >30 mL/min/1.73 m², a systolic BP target of 120-129 mm Hg is recommended if tolerated 1
• For patients with lower eGFR or kidney transplantation, individualized BP targets are recommended based on tolerability and impact on renal function and electrolytes 1

First-Line Treatment Selection

For CKD with Albuminuria:

• Severely increased albuminuria (A3) without diabetes: ACE inhibitors or ARBs are strongly recommended (Class 1B recommendation) 1
• Moderately increased albuminuria (A2) without diabetes: ACE inhibitors or ARBs are suggested (Class 2C recommendation) 1
• Moderately-to-severely increased albuminuria (A2 and A3) with diabetes: ACE inhibitors or ARBs are strongly recommended (Class 1B recommendation) 1

For CKD without Albuminuria:

• It may be reasonable to treat with ACE inhibitors or ARBs regardless of diabetes status 1

Dosing and Monitoring

• RASi should be administered at the highest approved dose that is tolerated to achieve maximum benefits 1
• Monitor changes in BP, serum creatinine, and serum potassium within 2-4 weeks of initiation or dose increase 1
• Continue ACE inhibitor or ARB therapy 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 rather than decreasing the dose or stopping RASi 1

Special Considerations

• Avoid any combination of ACE inhibitor, ARB, and direct renin inhibitor therapy in patients with CKD (Class 1B recommendation) 1
• For treatment-resistant hypertension, mineralocorticoid receptor antagonists (e.g., spironolactone) are effective but may cause hyperkalemia or reversible decline in kidney function, particularly in patients with low eGFR 1, 2
• Consider reducing the dose or discontinuing ACE inhibitor or ARB in cases of symptomatic hypotension, uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms in kidney failure (eGFR <15 ml/min per 1.73 m²) 1

Second and Third-Line Agents

• Long-acting dihydropyridine calcium channel blockers and diuretics are reasonable second and third-line therapeutic options 2, 3
• Dihydropyridine CCBs should not be used as monotherapy in proteinuric CKD patients but always in combination with a RAAS blocker 3
• Thiazide-like diuretics such as chlorthalidone can be effective for patients with stage 4 CKD and uncontrolled hypertension 2

Common Pitfalls and Caveats

• Inadequate dosing of diuretics can result in fluid retention, while excessive doses may lead to volume contraction, increasing the risk of hypotension and renal insufficiency 1
• Non-dihydropyridine CCBs consistently reduce albuminuria and slow the decline in kidney function, making them potentially valuable in proteinuric CKD 3
• For black patients with CKD, initial antihypertensive treatment should include a diuretic or a calcium channel blocker, either in combination or with a RAS blocker 1
• The evidence for blood pressure targets in CKD has limitations, including open study designs, office-based BP measurements, and limited information about adverse events 4

By following these evidence-based recommendations, clinicians can effectively manage hypertension in patients with CKD, potentially slowing disease progression and reducing cardiovascular risk.