What are the medication options for a patient with Chronic Kidney Disease (CKD) and hypertension?

Medication Options for CKD with Hypertension

For patients with CKD and hypertension, initiate an ACE inhibitor or ARB as first-line therapy if albuminuria is present (≥30 mg/g), titrate to the maximum tolerated dose, target blood pressure <130/80 mmHg, and add SGLT2 inhibitors for patients with type 2 diabetes to reduce cardiovascular and renal risks. 1

Initial Assessment Required

• Measure urine albumin-to-creatinine ratio to stratify treatment—this single test determines whether RAS blockade is indicated and guides your entire medication strategy 2
• Check eGFR to determine medication dosing adjustments and contraindications 1
• Assess for diabetes status, as this fundamentally changes your medication algorithm 1

First-Line Antihypertensive Therapy

For Patients WITH Albuminuria (≥30 mg/g)

• Start ACE inhibitor or ARB immediately and titrate to the highest approved tolerated dose—this is the strongest recommendation (Grade 1B) for slowing CKD progression 1
• Target blood pressure <130/80 mmHg for all CKD patients with hypertension; consider <120-129 mmHg systolic for those with severely elevated albuminuria (≥300 mg/g) 1, 3
• Monitor serum creatinine and potassium within 2-4 weeks after initiation or dose changes 1, 3
• Continue RAS inhibitor even if creatinine increases up to 30% from baseline, unless symptomatic hypotension or uncontrolled hyperkalemia develops 1

For Patients WITHOUT Albuminuria (<30 mg/g)

• Do not use ACE inhibitor or ARB specifically for renal protection—other antihypertensive agents are equally effective for cardiovascular risk reduction in this population 1, 2
• Choose from calcium channel blockers, thiazide-like diuretics, or beta-blockers to achieve blood pressure target <130/80 mmHg 3, 4

Second-Line Antihypertensive Agents

• Add long-acting dihydropyridine calcium channel blocker (e.g., amlodipine) as second-line therapy 3, 4
• Add thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) as third-line, effective even in stage 4 CKD (eGFR 15-30 mL/min/1.73 m²) 4
• For treatment-resistant hypertension, add spironolactone 12.5-25 mg daily, but monitor potassium closely—risk of hyperkalemia increases significantly with eGFR <45 mL/min/1.73 m² 1, 4

Glucose-Lowering Medications (If Diabetic)

SGLT2 Inhibitors (Highest Priority)

• Initiate SGLT2 inhibitor for all patients with type 2 diabetes and CKD stage 3 or higher (eGFR <60 mL/min/1.73 m²), regardless of glycemic control—these agents slow CKD progression and reduce heart failure risk independent of glucose management 1
• Continue SGLT2 inhibitors even as eGFR declines, as renal and cardiovascular benefits persist 1

Metformin

• Do not initiate metformin if eGFR <45 mL/min/1.73 m² 1
• Contraindicated if eGFR <30 mL/min/1.73 m² 1
• Reassess risk-benefit when eGFR falls to <45 mL/min/1.73 m² in patients already taking metformin 1
• Temporarily discontinue before iodinated contrast procedures if eGFR 30-60 mL/min/1.73 m² 1

GLP-1 Receptor Agonists

• Consider GLP-1 RA for cardiovascular risk reduction in patients with type 2 diabetes and CKD, particularly if SGLT2 inhibitor is insufficient 1

Insulin

• Adjust insulin doses as eGFR declines—reduced renal clearance increases hypoglycemia risk 1

Lipid Management

• Initiate statin therapy for all CKD patients to reduce cardiovascular risk, which is the leading cause of death in this population 1, 5, 6

Antiplatelet Therapy

• Use aspirin for secondary prevention in patients with established cardiovascular disease 1
• Consider aspirin for primary prevention in high-risk individuals, but balance against increased bleeding risk, especially with low eGFR 1

Critical Medication Adjustments and Avoidance

• Avoid NSAIDs entirely—these are nephrotoxic and accelerate CKD progression 5, 7
• Adjust antibiotic dosing based on eGFR for renally cleared agents 5, 7
• Never combine ACE inhibitor + ARB—this increases risks of hyperkalemia and acute kidney injury without additional benefit 1, 2
• Avoid direct renin inhibitors (e.g., aliskiren) in combination with RAS blockade 2

Monitoring Protocol

• Check basic metabolic panel (creatinine, potassium) within 2-4 weeks after starting or titrating RAS inhibitors 1, 3
• Monitor hemoglobin A1c at least every 3 months if diabetic, targeting ≤7% in most patients (may be less intensive if life expectancy <10 years or severe comorbidities) 1
• Use home blood pressure monitoring to detect masked hypertension and avoid overtreatment 3, 4
• Recheck urine albumin-to-creatinine ratio annually to assess treatment response 5, 7

Common Pitfalls to Avoid

• Do not discontinue RAS inhibitor for creatinine increases <30%—this is an expected hemodynamic effect and does not indicate harm 1
• Do not target blood pressure <110/70 mmHg—excessive lowering increases risks of falls, acute kidney injury, and hospitalization 3
• Do not withhold SGLT2 inhibitors due to modest eGFR decline—the initial dip in eGFR is hemodynamic and protective long-term 1
• Do not use combination RAS blockade despite persistent albuminuria—harm outweighs benefit 1, 2

Lifestyle Modifications (Essential Adjuncts)

• Restrict sodium intake to <2 g/day (5 g salt)—this enhances effectiveness of RAS blockade 1, 2
• Limit protein intake to 0.8 g/kg/day for patients with eGFR <60 mL/min/1.73 m²; avoid high protein intake >1.3 g/kg/day 2
• Smoking cessation is mandatory—tobacco accelerates CKD progression 1
• Regular exercise improves blood pressure control and cardiovascular outcomes 1