Hypertension Management in a 63-Year-Old Woman with Stage 3b CKD
For this 63-year-old woman with severe hypertension (180/90 mmHg) and stage 3b chronic kidney disease (GFR 34 ml/min), start with an ACE inhibitor (lisinopril 2.5-5 mg daily) or ARB (losartan 25-50 mg daily) as first-line therapy, with the expectation of adding a calcium channel blocker and then a thiazide-like diuretic if blood pressure remains uncontrolled. 1, 2
First-Line Agent Selection
ACE inhibitors or ARBs are the preferred initial agents for patients with chronic kidney disease (GFR 34 ml/min), as they provide renal protection beyond blood pressure lowering alone. 1
Start with lisinopril 2.5-5 mg once daily given the reduced GFR (34 ml/min), as lower starting doses are required when GFR is below 60 ml/min. 3, 4
Alternatively, losartan 25-50 mg once daily is appropriate if ACE inhibitor is not tolerated (due to cough or angioedema). 1, 5
These agents have been specifically studied and proven effective in patients with renal impairment, maintaining or even improving GFR in many cases. 3, 6, 4
Critical Monitoring Requirements
Check serum potassium and creatinine 1-2 weeks after initiating ACE inhibitor/ARB therapy, as hyperkalemia and acute kidney injury are the primary risks in patients with reduced GFR. 2, 5
An initial decline in GFR of up to 30% is acceptable and may actually predict long-term renal stability, as this reflects beneficial reduction in intraglomerular pressure rather than structural damage. 7
If creatinine rises more than 30% or potassium exceeds 5.5 mEq/L, hold the medication and reassess. 5
Sequential Treatment Algorithm
If blood pressure remains ≥140/90 mmHg after 3 months on optimized ACE inhibitor/ARB (lisinopril 20-40 mg or losartan 100 mg), add amlodipine 5-10 mg daily as the second agent. 2
The combination of ACE inhibitor/ARB plus calcium channel blocker provides complementary mechanisms—vasodilation and renin-angiotensin system blockade—with superior blood pressure control compared to either agent alone. 2
If blood pressure remains uncontrolled on dual therapy, add chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to longer duration of action) as the third agent to achieve guideline-recommended triple therapy. 2, 8
Special Considerations for This Patient
Avoid loop diuretics (furosemide/Lasix) as they are NOT first-line agents for hypertension and are reserved for volume overload states like heart failure. 9
Do not combine an ACE inhibitor with an ARB, as dual RAS blockade increases risks of hyperkalemia and acute kidney injury without additional cardiovascular benefit. 5
Given her age (63 years), start with lower doses and titrate gradually over 3-6 months to minimize risk of orthostatic hypotension and acute GFR decline. 8
Target Blood Pressure and Timeline
Target blood pressure is <140/90 mmHg minimum, with consideration of <130/80 mmHg if tolerated without adverse effects. 1, 2
Reassess blood pressure monthly during titration, with the goal of achieving target within 3 months of initiating or modifying therapy. 1, 2
Measure blood pressure in both arms at the first visit and consider home blood pressure monitoring (target <135/85 mmHg) to confirm sustained hypertension and avoid white coat effect. 8
Common Pitfalls to Avoid
Do not delay treatment intensification—this patient has stage 2 hypertension (180/90 mmHg) requiring prompt action to reduce cardiovascular and renal risk. 2
Do not use NSAIDs concurrently, as they can worsen renal function and attenuate the antihypertensive effect of ACE inhibitors/ARBs, particularly in elderly patients with compromised renal function. 5
Do not assume treatment failure without first confirming medication adherence, as non-adherence is the most common cause of apparent treatment resistance. 2
Monitor for postural hypotension at each visit, as elderly patients with renal impairment are at increased risk for orthostatic symptoms. 8, 9