What is the recommended blood pressure management for patients with impaired renal function, specifically those with an estimated Glomerular Filtration Rate (eGFR) of less than 30 milliliters per minute per 1.73 square meters?

Blood Pressure Management in Patients with eGFR <30 mL/min/1.73 m²

For patients with eGFR <30 mL/min/1.73 m², blood pressure should be monitored at every clinic visit (at least every 3 months), with a target of systolic <130 mmHg and diastolic <80 mmHg, using ACE inhibitors or ARBs as first-line agents despite the reduced kidney function. 1

Blood Pressure Monitoring Requirements

• Check blood pressure at every clinic visit, which must occur at least every 3 months 1
• This intensive monitoring schedule is critical given the high cardiovascular risk in this population

Blood Pressure Targets and Treatment Initiation

When blood pressure is elevated (systolic ≥130 mmHg OR diastolic ≥80 mmHg):

• Initiate therapeutic lifestyle changes immediately 1
• Intensify antihypertensive therapy 1
• Target systolic blood pressure to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 1

First-Line Antihypertensive Agent Selection

ACE inhibitors or ARBs remain the first-line agents even when eGFR <30 mL/min/1.73 m² 1

This recommendation may seem counterintuitive given concerns about hyperkalemia and acute kidney injury, but the guideline evidence supports their use as first-line therapy in this population. The Renal Physicians Association explicitly states that patients with GFR <30 mL/min/1.73 m² and hypertension should receive an ACE inhibitor or ARB as first-line therapy (Grade C recommendation). 1

Important Caveats:

• While European Society of Cardiology guidelines suggest ACE inhibitors/ARBs only if eGFR >30 mL/min/1.73 m², this represents a more conservative European approach 2
• Monitor closely for hyperkalemia and acute changes in kidney function
• If ACE inhibitors/ARBs must be used cautiously or are contraindicated due to hyperkalemia or severe renal dysfunction, amlodipine provides a safe alternative 2

Alternative Agents When RAAS Inhibitors Are Contraindicated

Amlodipine is the preferred alternative when ACE inhibitors/ARBs cannot be used 2

Benefits of amlodipine in this population:

• Reduces renal artery smooth muscle contraction, leading to higher renal blood flow even while systemic blood pressure decreases 2
• A single dose can demonstrably increase eGFR in CKD patients 2
• Provides effective blood pressure control when RAAS inhibitors must be limited due to hyperkalemia risk 2

Additional Management Considerations

Beyond blood pressure control, patients with eGFR <30 mL/min/1.73 m² require comprehensive management:

Medication Adjustments:

• Discontinue metformin - do not initiate if not already on it 1
• Discontinue SGLT2 inhibitors - though emerging evidence from CREDENCE suggests canagliflozin may be continued with benefit even below eGFR 30 3
• Consider GLP-1 receptor agonists, insulin, DPP-4 inhibitors, or other agents for glycemic control 1

Monitoring Requirements:

• Nutritional status (body weight and serum albumin) every 3 months 1
• Hemoglobin every 3 months 1
• Dyslipidemias (triglycerides, LDL, HDL, total cholesterol) 1
• Mineral bone disease parameters 1

Renal Replacement Therapy Planning:

• Begin discussing modality of renal replacement therapy 1
• If eGFR <20 mL/min/1.73 m² with malnutrition unresponsive to nutritional intervention, initiate RRT 1

Common Pitfalls to Avoid

1. Do not withhold ACE inhibitors/ARBs solely based on eGFR <30 - they remain first-line unless specific contraindications exist 1
2. Do not continue metformin - this is an absolute contraindication at eGFR <30 1
3. Do not assume SGLT2 inhibitors are absolutely contraindicated - while standard practice is to discontinue at eGFR <30, post-hoc analysis of CREDENCE showed benefit and safety even below this threshold 3
4. Do not neglect frequent monitoring - these patients require at least quarterly visits with blood pressure checks 1