Is it safe to forgo treatment for hypertension in patients with Chronic Kidney Disease (CKD)?

Forgoing Hypertension Treatment in CKD is Unsafe and Not Recommended

Treatment of hypertension in patients with chronic kidney disease is essential and should never be forgone, as untreated hypertension accelerates kidney disease progression, dramatically increases cardiovascular mortality, and significantly worsens quality of life. 1, 2

Why Treatment Cannot Be Avoided

Cardiovascular and Mortality Risk

• Patients with CKD face cardiovascular death risk that far exceeds their risk of progressing to end-stage kidney disease, making blood pressure control critical for survival 1, 3
• Hypertension is both a cause and consequence of CKD, creating a bidirectional relationship where untreated hypertension worsens kidney function, which in turn further elevates blood pressure 3, 4
• The residual cardiovascular risk remains high even after achieving blood pressure targets, underscoring that any treatment is better than no treatment 3

Kidney Disease Progression

• Uncontrolled hypertension directly accelerates the decline in kidney function, particularly in patients with albuminuria 1, 5
• Blood pressure control is fundamental to limiting progression of renal damage 6

Mandatory Treatment Approach

Blood Pressure Targets

• All adults with CKD and hypertension must be treated to a blood pressure goal of less than 130/80 mmHg 1, 2, 7
• For patients with eGFR >30 mL/min/1.73 m², target systolic blood pressure of 120-129 mmHg if tolerated provides additional cardiovascular and renal protection 2, 8, 7

First-Line Medication (Non-Negotiable)

• ACE inhibitors are the required first-line agent for all CKD patients with hypertension, particularly those with stage 3 or higher CKD or any degree of albuminuria 1, 2, 8, 7
• If ACE inhibitors are not tolerated, ARBs must be used as the alternative 1, 2, 8, 7
• These medications must be administered at the highest approved dose that is tolerated to achieve maximum renoprotective benefits 2, 8

Additional Therapy Requirements

• Most CKD patients require multiple antihypertensive medications to achieve blood pressure targets 5, 4
• Second-line therapy should include either a long-acting dihydropyridine calcium channel blocker OR a thiazide-type diuretic 2
• Third-line therapy adds whichever class (CCB or diuretic) was not yet used 2

Special Considerations That Do Not Justify Avoiding Treatment

Elderly and Frail Patients

• The same blood pressure targets and medication choices apply to elderly patients (>80 years), provided treatment is well tolerated 2
• While the KDIGO target of <120 mmHg systolic has been criticized for elderly/frail patients due to fall and fracture risk, this does not justify avoiding treatment entirely—it simply means targeting <130/80 mmHg instead 1
• Treatment decisions must weigh the risk of postural hypotension against the risk of disabling or fatal cardiovascular events like stroke 1

Monitoring to Ensure Safety (Not Reasons to Avoid Treatment)

• Check blood pressure, serum creatinine, and serum potassium within 2-4 weeks of starting or increasing ACE inhibitor/ARB dose 2, 8
• Continue the ACE inhibitor or ARB unless serum creatinine rises by more than 30% within 4 weeks 2, 8
• Hyperkalemia associated with ACE inhibitor/ARB use can often be managed with measures to reduce serum potassium rather than stopping the medication 2

Critical Pitfalls of Avoiding Treatment

Volume Management is Essential

• Dietary sodium restriction and diuretic therapy are fundamental, as CKD patients are extremely salt-sensitive 1, 6
• Inadequate diuretic dosing leads to fluid retention and poor blood pressure control, while excessive dosing causes volume contraction and worsening renal function 2, 8, 7
• Loop diuretics at adequate doses should represent the cornerstone of therapy, with daily body weight loss limited to 0.3-0.5 kg during initial treatment to prevent excessive hypovolemia 6

Do Not Stop Effective Therapy

• Do not discontinue antihypertensive medications simply because blood pressure falls below target if the patient tolerates the regimen without adverse effects 2

Absolute Contraindications Are Limited

• The only absolute contraindication to ACE inhibitors/ARBs is pregnancy 2
• Never combine an ACE inhibitor, ARB, and direct renin inhibitor together—this increases adverse events without additional benefit 2, 8, 7

The Bottom Line

There is no safe scenario in which hypertension treatment can be forgone in CKD patients. The evidence overwhelmingly demonstrates that untreated hypertension leads to accelerated kidney failure, cardiovascular events, and premature death. While treatment must be individualized regarding specific targets and medication choices based on age, frailty, and tolerability, some form of antihypertensive therapy is mandatory for all CKD patients with elevated blood pressure. 1, 2, 3, 4