What are the guidelines for managing hypertension in patients with Chronic Kidney Disease (CKD)?

Antihypertensive Management in CKD Patients

All adults with CKD and hypertension should be treated to a blood pressure goal of less than 130/80 mmHg, with ACE inhibitors as first-line therapy (or ARBs if ACE inhibitors are not tolerated). 1

Blood Pressure Targets

• Target BP <130/80 mmHg for all CKD patients with hypertension 1, 2, 3
• For patients with moderate-to-severe CKD (eGFR >30 mL/min/1.73 m²), aim for systolic BP of 120-129 mmHg if tolerated, as this provides additional cardiovascular and renal protection 2, 3
• This represents a shift from older KDIGO guidelines which recommended <140/90 mmHg for patients without albuminuria and <130/80 mmHg only for those with albuminuria ≥30 mg/24h 1

The more aggressive 2017 ACC/AHA targets supersede the 2013 KDIGO recommendations and reflect newer evidence showing benefit from tighter control for reducing cardiovascular events and slowing CKD progression. 1

First-Line Medication Selection

ACE inhibitors are the preferred first-line agent for all CKD patients with hypertension 1, 2, 3:

• For CKD stage 3 or higher (regardless of albuminuria): ACE inhibitors are strongly recommended to slow kidney disease progression 1, 2
• For CKD stage 1-2 with albuminuria ≥300 mg/d (or ≥300 mg/g albumin-to-creatinine ratio): ACE inhibitors are strongly recommended 1, 2
• If ACE inhibitor is not tolerated: ARBs may be used as an alternative 1, 2, 3, 4
• Administer at the highest approved dose that is tolerated to achieve maximum renoprotective benefits 2, 5

Monitoring After Initiation

Check blood pressure, serum creatinine, and serum potassium within 2-4 weeks of starting or increasing the dose of an ACE inhibitor or ARB 2, 5:

• Continue the ACE inhibitor or ARB unless serum creatinine rises by more than 30% within 4 weeks of initiation or dose increase 2, 5
• Hyperkalemia associated with ACE inhibitor/ARB use can often be managed with measures to reduce serum potassium rather than stopping the medication 2

Add-On Therapy When BP Goal Not Achieved

When BP remains above target on ACE inhibitor/ARB monotherapy 2:

• Second-line: Add either a long-acting dihydropyridine calcium channel blocker OR a thiazide-type diuretic 2
• Third-line: Add the other class not yet used (CCB or diuretic) 2
• For treatment-resistant hypertension: Consider adding spironolactone, though monitor carefully for hyperkalemia in moderate-to-advanced CKD 6

Special Population Considerations

Black patients with CKD: Initial therapy should include a thiazide-type diuretic or calcium channel blocker, either alone or in combination with an ACE inhibitor/ARB 2, 5

Kidney transplant recipients: Use a dihydropyridine calcium channel blocker as first-line therapy, as this improves GFR and kidney survival in transplant patients 1, 2, 3

Elderly patients (>80 years): Apply the same BP targets and medication choices as younger patients, provided treatment is well tolerated 2

Critical Contraindications

Never combine an ACE inhibitor, ARB, and direct renin inhibitor together in CKD patients—this increases adverse events without additional benefit 2, 3, 5

ACE inhibitors and ARBs are absolutely contraindicated during pregnancy 2

Use caution with ACE inhibitors/ARBs in patients with peripheral vascular disease due to association with renovascular disease 2

Common Pitfalls to Avoid

• Inadequate diuretic dosing leads to fluid retention and poor BP control, while excessive dosing causes volume contraction, hypotension, and worsening renal function 2, 3, 5
• Do not discontinue antihypertensive medications simply because BP falls below target if the patient tolerates the regimen without adverse effects—continue the effective therapy 2
• Avoid atenolol as it is less effective than placebo in reducing cardiovascular events 1
• Many patients will require multiple agents (often 3 or more) to achieve BP goals in CKD 7, 8