What are the initial antihypertensive (blood pressure lowering) therapy recommendations for patients with Chronic Kidney Disease (CKD)?

Initial Antihypertensive Therapy Recommendations for Patients with Chronic Kidney Disease (CKD)

For patients with CKD, initial antihypertensive therapy should include an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB), particularly in those with albuminuria ≥300 mg/d. 1

First-Line Therapy Selection

• For CKD patients with albuminuria ≥300 mg/d (severely increased): Start with an ACEI or ARB as first-line therapy regardless of diabetes status 1

  • Strong recommendation for ACEI in non-diabetic CKD with severely increased albuminuria 1
  • Strong recommendation for ACEI or ARB in diabetic CKD with moderately to severely increased albuminuria 1

• For CKD patients with moderate albuminuria (30-299 mg/d):

  • With diabetes: ACEI or ARB is recommended as first-line therapy 1
  • Without diabetes: ACEI or ARB is suggested as first-line therapy (weaker recommendation) 1

• For CKD patients without significant albuminuria: Any first-line antihypertensive agent can be used (thiazide diuretic, calcium channel blocker, ACEI, or ARB) 1

Blood Pressure Targets

• Target BP for CKD patients: <130/80 mmHg 1
  • This target applies to all age groups with CKD 1
  • For patients with persistent high-level macroalbuminuria (ACR ≥500 mg/g), consider an even lower systolic BP goal, but avoid levels <110 mmHg 1

Medication Selection Based on Patient Characteristics

• Black patients with CKD:

  • Initial therapy should be a thiazide-type diuretic or calcium channel blocker 1
  • If BP control is achieved with a single agent and the patient has proteinuria, an ACEI or ARB should be used 1

• Non-black patients with CKD:

  • Can start with ACEI, ARB, thiazide-type diuretic, or calcium channel blocker 1
  • All patients with CKD should eventually be taking an ACEI or ARB, but it doesn't have to be the initial therapy unless there is significant proteinuria 1

Combination Therapy Considerations

• Multiple antihypertensive agents are usually required to reach target BP in CKD patients 1

• Effective combinations include:

  • ACEI or ARB + diuretic 1, 2
  • ACEI or ARB + calcium channel blocker 3

• Important cautions:

  • Avoid combining ACEI + ARB + direct renin inhibitor due to increased risk of adverse effects without additional benefit 1
  • Dihydropyridine calcium channel blockers should not be used as monotherapy in proteinuric CKD but always in combination with a RAAS blocker 4

Medication Dosing in CKD

• For patients with reduced renal function:
  • For creatinine clearance ≥10 mL/min and ≤30 mL/min, reduce the initial dose of ACEI (e.g., lisinopril) to half of the usual recommended dose 5
  • For patients on hemodialysis or creatinine clearance <10 mL/min, the recommended initial dose of lisinopril is 2.5 mg once daily 5

Special Considerations

• Volume status: Diuretics are often necessary in CKD patients due to common volume overload 2

  • Thiazide diuretics are effective in early CKD stages 3
  • Loop diuretics may be needed in advanced CKD with signs of volume overload 1

• Potassium monitoring: Regular monitoring of serum potassium is essential when using ACEI or ARB therapy in CKD patients, especially in advanced stages 6

• Renal function monitoring: Check serum creatinine 2 weeks after starting ACEI/ARB therapy in patients with serum creatinine >2 mg/dL 6

  • A rise in serum creatinine up to 30% may occur and is generally acceptable 1

Common Pitfalls to Avoid

• Don't discontinue medications just because BP falls below target if the patient is tolerating therapy well 1

• Don't use dihydropyridine calcium channel blockers alone in proteinuric CKD patients 1, 4

• Don't combine ACEI and ARB therapy except in specific cases of controlled BP with persistent high-level macroalbuminuria 1

• Don't avoid ACEI/ARB due to mild-moderate increases in creatinine (up to 30% increase can be expected and is often a sign of effective intraglomerular pressure reduction) 1