What is the best approach to manage hypertension in an elderly patient with impaired renal function?

Management of Hypertension in an Elderly Patient with Impaired Renal Function

Target a blood pressure of <130/80 mm Hg in this elderly patient with chronic kidney disease (creatinine 1.5), as patients with CKD derive the same cardiovascular mortality benefit from intensive BP control as those without CKD, even in those ≥75 years of age. 1

Blood Pressure Target

• Aim for BP <130/80 mm Hg based on the 2017 ACC/AHA guidelines, which apply to all patients with CKD including the elderly 1
• The SPRINT trial demonstrated that intensive BP control (SBP target <120 mm Hg) reduced cardiovascular events and all-cause mortality equally in elderly patients with CKD, including those ≥75 years with frailty or slow gait speed 1
• Use incremental BP reduction with careful monitoring of physical and kidney function, as a 10-25% increase in serum creatinine may occur with ACE inhibitor or ARB therapy 1
• If the patient cannot tolerate <130/80 mm Hg due to adverse effects (hypotension, syncope, electrolyte abnormalities), accept BP 140-145/80 mm Hg 1

First-Line Medication Selection

Start with an ACE inhibitor (such as lisinopril) or ARB (such as losartan) as the preferred initial agent 1, 2:

• ACE inhibitors or ARBs are the preferred first-line drugs for hypertension with CKD, particularly if albuminuria ≥300 mg/day is present 1
• These agents reduce intraglomerular pressure and albuminuria, though serum creatinine may increase up to 30% due to hemodynamic effects 1
• Monitor serum creatinine and potassium closely; investigate further GFR decline beyond 30% for volume contraction, nephrotoxic agents, or renovascular disease 1
• Never combine an ACE inhibitor with an ARB, as dual RAS blockade increases risks of hypotension, hyperkalemia, and acute kidney injury without additional benefit 3, 4

Medication Escalation Algorithm

If BP remains uncontrolled on ACE inhibitor/ARB monotherapy 2:

1. Add amlodipine (calcium channel blocker) as the second agent, providing complementary vasodilation 2
2. Add a thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) as the third agent for triple therapy 2
3. Add spironolactone 25-50 mg daily as the fourth agent if BP remains uncontrolled on optimized triple therapy, as it provides significant additional BP reduction (average 25/12 mm Hg) in resistant hypertension 2

Special Considerations for Elderly Patients with CKD

• Use a stepped-care approach rather than starting with two-drug therapy when initiating treatment in elderly patients with SBP ≥150 mm Hg 1
• Exclude patients with standing SBP <110 mm Hg from intensive BP targets due to increased risk of hypotension and syncope 1
• Monitor closely for acute kidney injury, the most common adverse effect with intensive BP lowering in elderly patients 1
• Check for orthostatic hypotension at each visit by measuring BP while standing 5
• Monitor serum potassium and creatinine within 2-4 weeks after initiating or titrating ACE inhibitors/ARBs, as elderly patients on these agents are at increased risk for hyperkalemia 3, 4

Critical Drug Interactions to Avoid

• Discontinue or avoid NSAIDs (including COX-2 inhibitors), as they attenuate antihypertensive effects and may cause acute renal failure in elderly, volume-depleted patients on ACE inhibitors/ARBs 3, 4
• Avoid potassium-sparing diuretics (beyond spironolactone for resistant hypertension) and potassium supplements unless specifically indicated, due to hyperkalemia risk with ACE inhibitors/ARBs 3, 4
• Monitor lithium levels if prescribed, as ACE inhibitors and ARBs increase lithium toxicity risk 3, 4

Monitoring Parameters

• Reassess BP within 2-4 weeks after adding or titrating medications, with goal of achieving target BP within 3 months 2
• Monitor serum creatinine and potassium at baseline, 2-4 weeks after medication changes, and periodically thereafter 1
• Accept up to 30% increase in serum creatinine as a hemodynamic effect of ACE inhibitor/ARB therapy; investigate further increases 1
• Assess for orthostatic hypotension, syncope, and electrolyte abnormalities at each visit 1, 5