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

Treatment of Hypertension in Chronic Kidney Disease (CKD)

For patients with hypertension and CKD, ACE inhibitors or ARBs should be the first-line treatment, with a blood pressure goal of less than 130/80 mmHg. 1, 2

Blood Pressure Targets

• Adults with hypertension and CKD should be treated to a BP goal of less than 130/80 mmHg 1
• For patients with moderate-to-severe CKD with eGFR >30 mL/min/1.73 m², a systolic BP target of 120-129 mmHg is recommended if tolerated 2
• For patients with lower eGFR or kidney transplantation, individualized BP targets should be based on tolerability and impact on renal function and electrolytes 2

First-Line Medication Selection

• For patients with CKD stage 3 or higher OR stage 1-2 with albuminuria (≥300 mg/d or ≥300 mg/g albumin-to-creatinine ratio), an ACE inhibitor is recommended to slow kidney disease progression 1
• If an ACE inhibitor is not tolerated, an ARB may be used as an alternative 1, 3
• ACE inhibitors or ARBs are strongly recommended for:
  • Severely increased albuminuria (A3) without diabetes 2
  • Moderately increased albuminuria (A2) with diabetes 2, 3
  • Moderately-to-severely increased albuminuria (A2 and A3) with diabetes 2, 3

Special Considerations for Different Patient Populations

• For black patients with CKD, initial antihypertensive treatment should include a diuretic or a calcium channel blocker, either alone or in combination with a RAS blocker 2, 3
• For kidney transplant recipients, a dihydropyridine calcium channel blocker is recommended as first-line therapy due to improved GFR and kidney survival 1, 3
• In elderly patients with CKD, the same guidelines apply as for younger patients, provided BP-lowering treatment is well tolerated 3

Add-on Therapies and Medication Algorithm

1. First choice: ACE inhibitor or ARB, particularly if albuminuria is present 3, 4
2. If additional BP lowering needed: Add dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic 3, 5
3. For resistant hypertension: Consider adding mineralocorticoid receptor antagonist (spironolactone) with close monitoring of potassium and renal function 3, 5

Dosing and Monitoring

• RAS inhibitors should be administered at the highest approved dose that is tolerated to achieve maximum benefits 2, 4
• Monitor changes in BP, serum creatinine, and serum potassium within 2-4 weeks of initiation or dose increase of ACE inhibitor or ARB 2, 3
• Continue ACE inhibitor or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation or dose increase 2, 3

Important Contraindications and Precautions

• Avoid any combination of ACE inhibitor, ARB, and direct renin inhibitor therapy in patients with CKD 2, 3
• Consider reducing the dose or discontinuing ACE inhibitor or ARB in cases of:
  • Symptomatic hypotension
  • Uncontrolled hyperkalemia despite medical treatment
  • Advanced kidney failure (eGFR <15 ml/min per 1.73 m²) to reduce uremic symptoms 2, 3
• Diuretics require careful dosing - inadequate doses can result in fluid retention, while excessive doses may lead to volume contraction, increasing the risk of hypotension and renal insufficiency 1, 2
• For patients with serum creatinine >2 mg/dL, start ACE inhibitors or ARBs at lower doses and monitor serum creatinine and potassium every 2 weeks initially 6

Role of Other Antihypertensive Medications

• Dihydropyridine calcium channel blockers should not be used as monotherapy in proteinuric CKD patients but always in combination with a RAAS blocker 4
• Non-dihydropyridine calcium channel blockers can reduce albuminuria and slow decline in kidney function 4
• Diuretics are cornerstone agents in CKD management, particularly for volume control 4, 5
• For treatment-resistant hypertension, chlorthalidone has shown effectiveness in stage 4 CKD 5

By following this evidence-based approach to hypertension management in CKD patients, clinicians can help slow disease progression and reduce cardiovascular risk in this vulnerable population 7, 8.