What is the recommended management for hypertension in a patient with Chronic Kidney Disease (CKD)?

Management of Hypertension in CKD Patients

For adults with CKD and hypertension, target a blood pressure of <130/80 mmHg using an ACE inhibitor or ARB as first-line therapy, with the specific choice and intensity guided by the presence and severity of albuminuria. 1, 2, 3

Blood Pressure Targets

• Aim for <130/80 mmHg in all adults with CKD and hypertension 1, 2, 3
• For patients with moderate-to-severe CKD (eGFR >30 mL/min/1.73 m²), target systolic BP of 120-129 mmHg if tolerated, as this provides additional cardiovascular and renal protection 2, 3, 4
• This represents a shift from older JNC-8 guidelines that recommended <140/90 mmHg, reflecting newer evidence from trials like SPRINT showing cardiovascular and mortality benefits from tighter control 1, 3

Accurate Blood Pressure Measurement

• Use standardized office BP measurement: patient seated with back supported, feet flat on floor, after 5 minutes of rest 1
• Patient should avoid caffeine, exercise, and smoking for at least 30 minutes before measurement and should empty bladder beforehand 1
• Consider 24-hour ambulatory BP monitoring if office readings are elevated (≥120/70 mmHg in adults) to identify masked hypertension, which is common in CKD 1

First-Line Medication Selection by CKD Stage and Albuminuria

CKD with Severely Increased Albuminuria (A3, >300 mg/g)

• Strongly recommend ACE inhibitor or ARB for both diabetic and non-diabetic patients with CKD stages G1-G4 and severely increased albuminuria 1, 4
• This is a Grade 1B recommendation based on RCTs showing clear reduction in kidney failure and cardiovascular events 1

CKD with Moderately Increased Albuminuria (A2, 30-300 mg/g)

• Suggest ACE inhibitor or ARB for non-diabetic patients with CKD stages G1-G4 and moderately increased albuminuria 1, 4
• Strongly recommend ACE inhibitor or ARB for diabetic patients with moderately increased albuminuria 1, 4
• Evidence is weaker here (Grade 2C for non-diabetics) but cardiovascular benefits from trials like HOPE support this approach 1

CKD without Albuminuria

• Target BP <140/90 mmHg for patients without albuminuria 1
• ACE inhibitor or ARB may be reasonable but evidence is less robust 1
• Consider other antihypertensive classes based on comorbidities 1

Dosing and Monitoring Protocol

• Administer ACE inhibitor or ARB at the highest approved tolerated dose to achieve maximum renoprotective benefits proven in clinical trials 1, 3, 4
• Check BP, serum creatinine, and potassium within 2-4 weeks of initiating or increasing dose, with frequency depending on current GFR and potassium level 1, 3, 4
• Continue therapy unless creatinine rises >30% within 4 weeks of initiation or dose increase 1, 3, 4
• A small decline in eGFR (especially in first 6 months) is expected and represents hemodynamic effects, not harm 1

Add-On Therapy When BP Goal Not Achieved

Most CKD patients require combination therapy to reach BP targets:

• Second-line: Add either a long-acting dihydropyridine calcium channel blocker OR a thiazide-type diuretic 3
• Third-line: Add the other class not yet used (CCB or diuretic) 3
• For Black patients with CKD, initial therapy should include a thiazide-type diuretic or calcium channel blocker, either alone or combined with ACE inhibitor/ARB 3, 4

Managing Hyperkalemia

• Hyperkalemia from ACE inhibitor/ARB can often be managed with potassium-lowering measures rather than stopping the medication 1, 3
• Consider dietary potassium restriction, diuretic adjustment, or potassium binders before discontinuing renin-angiotensin system blockade 1
• Only reduce dose or discontinue ACE inhibitor/ARB for uncontrolled hyperkalemia despite medical treatment 1, 3

Special Population Considerations

Kidney Transplant Recipients

• Use dihydropyridine calcium channel blocker or ARB as first-line therapy (Grade 1C recommendation) 1, 2
• Target BP <130/80 mmHg using standardized office measurement 1

Advanced CKD (eGFR <30 mL/min/1.73 m²)

• For eGFR 10-30 mL/min: reduce initial ACE inhibitor dose to half the usual starting dose (e.g., lisinopril 5 mg instead of 10 mg) 5
• For eGFR <10 mL/min or hemodialysis: start with lisinopril 2.5 mg once daily 5
• Consider reducing or discontinuing ACE inhibitor/ARB when eGFR <15 mL/min to reduce uremic symptoms, but weigh against cardiovascular benefits 1, 3

Children with CKD (≥6 years)

• Target BP ≤50th percentile for age, sex, and height using 24-hour ambulatory BP monitoring 1
• Use ACE inhibitor or ARB as first-line therapy regardless of proteinuria level 1
• For lisinopril: start 0.07 mg/kg once daily (up to 5 mg), titrate to maximum 0.61 mg/kg (up to 40 mg) once daily 5

Critical Contraindications

• Never combine ACE inhibitor, ARB, and direct renin inhibitor in CKD patients—this increases adverse events (hyperkalemia, acute kidney injury) without additional benefit (Grade 1B recommendation) 1, 2, 3
• ACE inhibitors and ARBs are absolutely contraindicated in pregnancy 3
• Use caution in peripheral vascular disease due to association with renovascular disease 3

Mineralocorticoid Receptor Antagonists

• Effective for refractory/resistant hypertension but carry significant risk of hyperkalemia and reversible kidney function decline, particularly with low eGFR 1
• Reserve for treatment-resistant hypertension after optimizing other agents 6
• Newer non-steroidal mineralocorticoid receptor antagonists may offer safer alternatives 6, 7

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, 4
• Stopping ACE inhibitor/ARB prematurely for small creatinine increases (<30%) or manageable hyperkalemia loses critical cardiovascular and renal protection 1
• Using routine office BP instead of standardized measurement leads to inaccurate readings and inappropriate treatment decisions 1
• Discontinuing effective therapy simply because BP falls below target when patient tolerates the regimen without adverse effects 3