What is the best approach to manage a 76-year-old patient with chronically elevated systolic blood pressure (hypertension) and a history of chronic kidney disease (CKD)?

Management of Chronic Hypertension in a 76-Year-Old with CKD

For this 76-year-old patient with systolic BP chronically in the 170s and CKD, target a systolic BP of 130-139 mmHg using standardized office BP measurement, and initiate treatment with an ACE inhibitor or ARB as first-line therapy, adding a diuretic as second-line if needed. 1

Blood Pressure Target

• The 2024 ESC Guidelines specifically recommend targeting systolic BP to a range of 130-139 mmHg in older adults aged ≥65 years with CKD. 1

• The KDIGO 2021 guideline suggests a more aggressive target of <120 mmHg for most CKD patients, but this applies specifically to standardized office BP measurements and has been controversial in older adults. 1

• Given this patient's age (76 years), the ESC target of 130-139 mmHg is more appropriate and safer than the KDIGO <120 mmHg target, as overly aggressive BP lowering in elderly patients increases risks of falls, fractures, and symptomatic hypotension. 1

• The current BP of 170s systolic clearly exceeds all recommended targets and requires treatment. 1

First-Line Pharmacological Management

• Start with an ACE inhibitor or ARB as first-line therapy. 1, 2

• RAS inhibitors (ACEi/ARB) are particularly beneficial if the patient has albuminuria ≥30 mg/24h, as they provide renoprotective effects beyond BP control and slow CKD progression. 1, 2

• For patients with moderately increased albuminuria (A2) or severely increased albuminuria (A3), RAS inhibitors are strongly recommended. 1

• Losartan specifically is FDA-approved for treating hypertension and reducing progression of diabetic nephropathy in patients with elevated creatinine and proteinuria. 3

Second-Line and Additional Agents

• If BP target is not achieved with ACE inhibitor/ARB monotherapy, add a thiazide or thiazide-like diuretic as second-line therapy. 1, 2, 4

• The antihypertensive effects of ACE inhibitors and ARBs are significantly augmented by both dietary salt restriction and diuretic therapy. 2

• For stage 4 CKD with uncontrolled hypertension, chlorthalidone has demonstrated effectiveness even in advanced kidney disease. 4

• Long-acting dihydropyridine calcium channel blockers are reasonable third-line options and may slow CKD progression when combined with an ACE inhibitor. 2, 4

• Most patients will require 2-3 antihypertensive medications to achieve BP goals. 1, 3

Blood Pressure Measurement Technique

• Use standardized office BP measurement rather than routine casual BP readings, as the recommended targets apply specifically to standardized measurements. 1, 2

• Standardized measurement emphasizes adequate preparation (patient seated quietly for 5 minutes, proper cuff size, arm supported at heart level) rather than the type of equipment used. 1

• Consider ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to complement office readings and identify white coat hypertension, masked hypertension, or abnormal dipping patterns common in CKD. 1, 5

• Applying the KDIGO target of <120 mmHg to non-standardized BP measurements is potentially hazardous and inappropriate. 1

Lifestyle Modifications

• Recommend dietary sodium restriction to <2 g sodium per day (<90 mmol/day or <5 g sodium chloride/day). 1

• Salt restriction is particularly important in CKD patients and enhances the effectiveness of RAS inhibitors. 2, 4

• Advise moderate-intensity physical activity for at least 150 minutes per week, adjusted for the patient's cardiovascular fitness and physical tolerance. 1

• Address other cardiovascular risk factors including weight management if BMI >25 kg/m², limited alcohol intake, and smoking cessation. 3

Monitoring and Follow-Up

• Monitor serum creatinine, eGFR, and potassium levels within 2-4 weeks after initiating or adjusting RAS inhibitor therapy. 1, 2

• A rise in creatinine up to 30% above baseline is acceptable when starting ACE inhibitors/ARBs and does not require discontinuation. 1

• Check for albuminuria/proteinuria to guide intensity of therapy and choice of agents. 1, 2

• Monitor for symptoms of orthostatic hypotension, particularly given the patient's age, as elderly CKD patients are at higher risk. 1, 6

• Reassess BP control regularly and adjust medications as needed to maintain target of 130-139 mmHg systolic. 1

Critical Pitfalls to Avoid

• Do not target BP <120 mmHg in this 76-year-old patient using routine office BP measurements, as this significantly increases risk of adverse events including falls, acute kidney injury, and symptomatic hypotension without proven benefit in this age group. 1, 6

• Avoid overly aggressive BP lowering that results in diastolic BP <70 mmHg, which may compromise coronary perfusion. 1

• Do not combine ACE inhibitors with ARBs, as this increases risk of hyperkalemia and acute kidney injury without additional cardiovascular benefit. 6

• Be cautious with potassium-rich salt substitutes or DASH diet in advanced CKD due to hyperkalemia risk. 1

• Monitor closely for hyperkalemia when using RAS inhibitors, especially if adding spironolactone for resistant hypertension. 4

• The evidence for intensive BP control (<120 mmHg) is weakest and potentially harmful in elderly patients, those with advanced CKD (stage 4-5), and those with significant comorbidities. 1, 7, 8