Treatment of Hypertension in Chronic Kidney Disease
For patients with chronic kidney disease (CKD), ACE inhibitors or ARBs should be used as first-line therapy with a blood pressure target of less than 130/80 mmHg. 1, 2
Blood Pressure Targets
- Target blood pressure for adults with hypertension and CKD should be less than 130/80 mmHg 1, 2
- For patients with moderate-to-severe CKD with eGFR >30 mL/min/1.73 m², aim for a systolic BP target of 120-129 mmHg if tolerated 1, 2
- For patients with lower eGFR or kidney transplantation, BP targets should be adjusted 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, an ACE inhibitor is recommended to slow kidney disease progression 1
- If an ACE inhibitor is not tolerated, an ARB should be used as an alternative 1, 3
- For patients with severely increased albuminuria (A3) without diabetes, ACE inhibitors or ARBs are strongly recommended (Class 1B recommendation) 2
- For moderately increased albuminuria (A2) without diabetes, ACE inhibitors or ARBs are suggested (Class 2C recommendation) 2
- For patients with diabetes and moderately-to-severely increased albuminuria (A2 and A3), ACE inhibitors or ARBs are strongly recommended (Class 1B recommendation) 2
Dosing and Monitoring
- Administer renin-angiotensin system inhibitors (RASi) at the highest approved dose that is tolerated to achieve maximum benefits 2
- Monitor changes in BP, serum creatinine, and serum potassium within 2-4 weeks of initiation or dose increase 2
- Continue ACE inhibitor or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation or dose increase 2
- For patients with serum creatinine >2 mg/dL, start ARB at a lower dose and check serum creatinine and potassium every 2 weeks 4
Second-Line and Additional Therapies
- Diuretics are commonly used and represent a cornerstone in the management of CKD patients, especially for those with fluid retention 3, 5
- Long-acting dihydropyridine calcium channel blockers are reasonable second-line therapeutic options 5
- 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 2
- For kidney transplant recipients, a dihydropyridine calcium channel blocker is recommended as first-line therapy due to improved GFR and kidney survival 1
- For treatment-resistant hypertension, spironolactone may be added to the baseline regimen, but with careful monitoring for hyperkalemia in moderate-to-advanced CKD 5
- Chlorthalidone has been shown to be effective in patients with stage 4 CKD and uncontrolled hypertension 5
Important Contraindications and Precautions
- Avoid any combination of ACE inhibitor, ARB, and direct renin inhibitor therapy in patients with CKD 1, 2
- Non-dihydropyridine CCBs should not be used as monotherapy in proteinuric CKD patients but always in combination with a RAAS blocker 3
- Consider reducing the dose or discontinuing ACE inhibitor or ARB in cases of:
- Diuretics require careful dosing to avoid fluid retention or volume contraction, which can increase the risk of hypotension and renal insufficiency 1, 2
Special Considerations
- Accurate blood pressure measurement is essential for diagnosis and management of hypertension in CKD 5, 6
- Dietary sodium restriction can improve BP control, especially among patients treated with renin-angiotensin system blockers 5
- 24-hour ambulatory BP monitoring or home BP monitoring may be particularly valuable in CKD patients, where reduced or reverse dipping patterns, masked and resistant hypertension are frequent 6
- Even after achieving BP targets, the residual cardiovascular risk remains high in CKD patients 6
- Novel agents such as SGLT2 inhibitors may provide additional benefits beyond BP control in CKD patients 6