What are the recommended blood pressure medications for patients with impaired renal function?

Blood Pressure Medications in Renal Failure

ACE inhibitors or ARBs are the first-line antihypertensive agents for patients with renal impairment, particularly when proteinuria or albuminuria is present, and should be uptitrated to maximally tolerated doses despite modest increases in creatinine. 1

First-Line Therapy: RAS Inhibition

ACE inhibitors and ARBs are strongly recommended as initial therapy for hypertensive patients with chronic kidney disease (CKD), especially those with albuminuria. 1 These agents provide both blood pressure control and renoprotective effects by favorably altering renal hemodynamics and slowing progression of renal dysfunction. 2

Specific Recommendations by Clinical Context:

• With severely increased albuminuria (no diabetes): ACEi or ARB strongly recommended 1
• With moderately-to-severely increased albuminuria (with diabetes): ACEi or ARB strongly recommended 1
• Without albuminuria: RAS inhibition remains a reasonable option 1
• Proteinuric glomerular disease: Uptitrate to maximally tolerated dose even without hypertension 3

Dosing Adjustments in Renal Impairment:

For ramipril: Dose adaptation required if CrCl <30 mL/min (initial dose 1.25 mg daily, maximum 5 mg/day) 3

For losartan: No dose adjustment necessary in renal impairment unless volume depleted; start with 25 mg in hepatic impairment 4

For lisinopril: Start with 2.5 mg daily if GFR <30 mL/min, 5 mg if GFR 30-60 mL/min 5

Monitoring and Safety Parameters

Check serum creatinine and potassium within 2-4 weeks of initiating or increasing RAS inhibitor dose. 1 This is critical to detect hyperkalemia and acute kidney injury early.

When to Continue vs. Discontinue:

Continue ACEi/ARB if creatinine rises ≤30% within 4 weeks of initiation or dose increase. 1 This modest rise reflects hemodynamic changes and does not indicate harm. 3

Reduce dose or discontinue if:

• Creatinine rises >30% 1
• Symptomatic hypotension occurs 3
• Refractory hyperkalemia (K+ >5.0 mmol/L) despite treatment 3
• Advanced kidney failure (eGFR <15 mL/min/1.73 m²) with uremic symptoms 1

Managing Hyperkalemia Without Stopping RAS Inhibition:

Hyperkalemia can often be managed with potassium-lowering measures rather than discontinuing the RAS inhibitor. 1 This preserves the renoprotective benefits while addressing the electrolyte disturbance.

Add-On Therapy for Inadequate Blood Pressure Control

When RAS inhibition alone is insufficient:

Second-line: Add dihydropyridine calcium channel blocker (CCB) or thiazide/thiazide-like diuretic. 1 CCBs are particularly effective in renal impairment and do not require dose adjustment. 6, 2

For resistant hypertension: Add low-dose spironolactone with close monitoring of potassium and renal function, especially if eGFR <45 mL/min. 1 Mineralocorticoid receptor antagonists are highly effective but carry significant hyperkalemia risk in advanced CKD. 1

Diuretic Selection in Renal Failure

Loop diuretics (furosemide, bumetanide, torsemide) are required when GFR <30 mL/min or serum creatinine >2.0 mg/dL, as thiazides become ineffective. 2 Thiazides lose efficacy in moderate-to-severe renal impairment. 3

Diuretic Dosing Strategy:

• Use twice-daily dosing of loop diuretics over once-daily 3
• Increase dose until clinically significant diuresis or maximum effective dose reached 3
• Consider longer-acting agents (bumetanide, torsemide) if furosemide fails 3
• Combine with thiazide for synergistic effect in resistant edema 3

For atenolol: Reduce to 50 mg/day if CrCl 15-35 mL/min; reduce to 25 mg/day if CrCl <15 mL/min 3

Special Populations

Kidney transplant recipients: Start with dihydropyridine CCB or ARB as first-line therapy 1

Black patients: Initial therapy should include diuretic or CCB, alone or combined with RAS inhibitor 1

Elderly patients: Same guidelines apply if treatment is well-tolerated; test for orthostatic hypotension before starting or intensifying therapy 1

Blood Pressure Targets

**Target systolic BP <120 mmHg when tolerated in most CKD patients.** 1 For diabetic or non-diabetic CKD, systolic BP of 130-139 mmHg is acceptable. 1 In moderate-to-severe CKD (eGFR >30 mL/min/1.73 m²), target 120-129 mmHg if tolerated. 1

Critical Contraindications

Never combine ACEi + ARB + direct renin inhibitor - this triple combination increases adverse events without benefit. 1

RAS inhibitors are contraindicated in pregnancy. 1

Use caution in peripheral vascular disease due to association with renovascular disease. 1

Common Pitfalls to Avoid

• Do not stop ACEi/ARB for modest creatinine increases - up to 30% rise is acceptable and expected 3, 1
• Avoid NSAIDs, potassium supplements, and salt substitutes while on RAS inhibitors 3
• Do not use enoxaparin in severe renal failure (CrCl <30 mL/min) without dose adjustment to 1 mg/kg once daily 3
• Avoid metformin, glibenclamide, and atenolol when GFR ≤60 mL/min; use alternatives like metoprolol 7
• Do not abruptly discontinue all antihypertensives - use stepwise approach 8

Sodium Restriction

Restrict dietary sodium to <2.0 g/day (<90 mmol/day) in all patients with glomerular disease and edema. 3 This enhances diuretic efficacy and blood pressure control.