Management of Hypertension in an Elderly Female with eGFR 55 and Normal Microalbumin
This patient should be treated with standard antihypertensive therapy targeting BP <140/90 mmHg, with an ACE inhibitor or ARB as first-line therapy, recognizing that her Stage 3 CKD (eGFR 55) classifies her as high-risk requiring immediate pharmacological treatment regardless of BP level. 1
Risk Stratification and Treatment Urgency
The eGFR of 55 mL/min/1.73 m² indicates Stage 3 CKD, which automatically places this patient in a high cardiovascular risk category requiring immediate drug treatment, even if BP is only mildly elevated. 1
The absence of microalbuminuria is favorable but does not eliminate the increased cardiovascular risk conferred by reduced eGFR alone. Both reduced eGFR and microalbuminuria are independent risk factors, and their combination increases risk further, but isolated eGFR reduction still mandates aggressive treatment. 1, 2
The 2020 ISH guidelines explicitly state that patients with CKD should start drug treatment immediately as high-risk patients, without waiting for lifestyle intervention trials. 1
First-Line Pharmacological Approach
Start with an ACE inhibitor or ARB as the preferred initial agent:
ACE inhibitors or ARBs are the preferred first-line agents in patients with CKD, even without proteinuria, due to their renoprotective effects beyond BP lowering. 1
These agents provide additional protection against progression of renal damage through direct effects on glomerular hemodynamics, independent of BP reduction. 1, 3
A slight increase in serum creatinine (up to 20%) after initiating RAS blockade is expected and acceptable, and should not be interpreted as progressive renal deterioration. 1
Blood Pressure Targets
Target BP should be <140/90 mmHg, individualized based on frailty status:
The 2020 ISH guidelines recommend BP <140/90 mmHg for elderly patients, with individualization based on frailty rather than age alone. 1
The 2024 ESC guidelines suggest a more aggressive target of 120-129 mmHg systolic if well tolerated, but emphasize the "as low as reasonably achievable" (ALARA) principle when treatment is poorly tolerated. 1
Avoid excessive diastolic BP lowering below 60 mmHg, particularly in elderly patients, as this may be associated with increased cardiovascular mortality. 1
Expected Need for Combination Therapy
Anticipate requiring 2-3 antihypertensive medications:
Most elderly hypertensive patients require multiple drugs to achieve BP control, with only 24-28% achieving control on monotherapy. 4
If BP remains uncontrolled on ACE inhibitor/ARB monotherapy, add a dihydropyridine calcium channel blocker (DHP-CCB) as second-line, followed by a thiazide-like diuretic as third-line. 1
Single-pill combination therapy is recommended when using multiple agents to improve adherence. 1
Monitoring Strategy
Monitor the following parameters:
Recheck serum creatinine and eGFR within 1-2 weeks after initiating ACE inhibitor/ARB to assess for the expected modest rise in creatinine. 1
Recheck microalbuminuria periodically (every 6-12 months), as its development would further increase cardiovascular risk and strengthen the indication for RAS blockade. 1
Achieve target BP within 3 months of treatment initiation. 1
Monitor for orthostatic hypotension, particularly before intensifying therapy, by measuring BP after 5 minutes of sitting/lying and then 1-3 minutes after standing. 1
Common Pitfalls to Avoid
Do not withhold ACE inhibitors/ARBs due to concern about worsening renal function in Stage 3 CKD—the renoprotective benefits outweigh risks at this level of kidney function. 1
Do not combine two RAS blockers (ACE inhibitor plus ARB), as this is not recommended and provides no additional benefit. 1
Do not discontinue antihypertensive therapy based solely on age—treatment should be maintained lifelong, even beyond age 85, if well tolerated. 1
Do not rely on monotherapy expectations—prepare the patient for likely need of 2-3 medications to achieve adequate BP control. 4