What is the recommended treatment for a patient with Chronic Kidney Disease (CKD) stage 4 and Hypertension (blood pressure greater than 150 mmHg)?

Management of Hypertension in CKD Stage 4 with Blood Pressure >150 mmHg

For patients with CKD stage 4 and blood pressure greater than 150 mmHg, a target blood pressure of <140/90 mmHg is recommended, with ACE inhibitors or ARBs as preferred agents, often requiring multiple medications including diuretics for optimal management. 1

Blood Pressure Targets

• For patients with CKD stage 4, the recommended blood pressure target is <140/90 mmHg 1
• There is insufficient high-quality data for specific BP targets in advanced CKD (stages 4-5) as most major trials, including SPRINT, excluded patients with advanced CKD 1
• The Blood Pressure Control for Renoprotection in Patients With Non-Diabetic Chronic Renal Disease (REIN-2) trial, one of the few trials including CKD stage 4 patients, was stopped early for futility 1
• Caution is warranted with intensive BP lowering in advanced CKD as the risk of acute kidney injury is higher than in earlier CKD stages 1

First-Line Medication Recommendations

• ACE inhibitors or ARBs are recommended as preferred agents for patients with CKD 1
• The recommendation for ACE inhibitor use is graded as moderate strength, while ARB use is considered a weak recommendation 1
• For patients with albuminuria ≥300 mg/day, ACE inhibitors or ARBs are particularly beneficial 1
• When starting ACE inhibitors or ARBs, serum creatinine may increase up to 30% due to reduction in intraglomerular pressure, which is expected 1

Additional Medication Considerations

• Multiple medications are often required to achieve BP control in CKD patients 1, 2
• Options for BP reduction in advanced CKD include:
  • Thiazide-like diuretics (chlorthalidone has shown effectiveness in stage 4 CKD) 2
  • Calcium channel blockers (CCBs) 1
  • Loop diuretics (especially for volume control in advanced CKD) 1
• For black patients with CKD, initial therapy should include a thiazide diuretic or calcium channel blocker, with an ACE inhibitor or ARB added if proteinuria is present 1

Implementation Considerations

• Careful monitoring of kidney function and electrolytes is essential when using ACE inhibitors or ARBs in advanced CKD 3
• In CKD stages 4-5, the risk of AKI with intensive BP lowering is higher than in earlier CKD stages 1
• Among older individuals with CKD, diastolic BP is often low due to increased arterial stiffness, making aggressive systolic BP lowering potentially problematic 1
• Intensive BP lowering in advanced CKD may accelerate the need for kidney replacement therapy in some patients 1

Treatment Algorithm

1. Start with an ACE inhibitor (or ARB if ACE inhibitor not tolerated) 1
2. Add a thiazide-like diuretic (chlorthalidone has shown effectiveness in stage 4 CKD) 2
3. If BP remains uncontrolled, add a calcium channel blocker 1, 4
4. For volume overload, consider loop diuretics 1
5. For resistant hypertension, consider adding spironolactone with careful monitoring of potassium levels 1, 2

Common Pitfalls and Caveats

• Avoid dual RAAS blockade (combining ACE inhibitor and ARB) as this increases adverse events without additional benefit 1, 3
• Monitor for hyperkalemia when using ACE inhibitors or ARBs in advanced CKD 3
• Sodium restriction is often overlooked but can significantly improve BP control, especially when using RAAS blockers 2, 3
• Further GFR decline beyond the initial 30% after starting ACE inhibitors/ARBs should be investigated for other causes such as volume contraction, nephrotoxic agents, or renovascular disease 1
• Masked hypertension may occur in up to 30% of patients with CKD and is associated with worse outcomes, highlighting the importance of home or ambulatory BP monitoring 1, 5