Management of Hypertension in CKD Stage 3 and Above
All adults with hypertension and CKD stage 3 or higher should be treated to a blood pressure goal of less than 130/80 mmHg, with an ACE inhibitor as first-line therapy (or ARB if ACE inhibitor is not tolerated), particularly when albuminuria ≥300 mg/day is present. 1
Blood Pressure Target
- Target BP <130/80 mmHg for all patients with CKD stage 3 or higher, regardless of age or albuminuria status 1, 2, 3
- This target is supported by systematic review evidence showing cardiovascular and renal protection 1
- For patients with eGFR >30 mL/min/1.73 m², aim for systolic BP 120-129 mmHg if tolerated for additional cardiovascular and renal protection 2
First-Line Medication Selection
Start with an ACE inhibitor in all patients with CKD stage 3 or higher, especially those with albuminuria ≥300 mg/day or ≥300 mg/g albumin-to-creatinine ratio. 1, 3, 4
- ACE inhibitors slow kidney disease progression and are the reasonable first-line choice (Class IIa recommendation) 1, 3
- If ACE inhibitor is not tolerated, use an ARB as an alternative (Class IIb recommendation) 1, 3, 5
- Start at low doses and titrate to the highest approved dose that is tolerated, as trial benefits were achieved at these target doses 3, 4
Medication Algorithm
For patients WITH albuminuria ≥300 mg/day:
- Initiate ACE inhibitor as first-line therapy 1, 3, 4
- If ACE inhibitor causes intolerable side effects (cough, angioedema), switch to ARB 1, 3
For patients WITHOUT significant albuminuria (<300 mg/day):
- Use standard first-line antihypertensive choices (thiazide-type diuretics, calcium channel blockers, ACE inhibitors, or ARBs) 1, 3
Second-line therapy when BP goal not achieved:
- Add long-acting dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily) OR thiazide-type diuretic (chlorthalidone 12.5-25 mg daily) 2, 6
- Diuretics are essential in CKD for volume management and BP control 2, 6
Third-line therapy for resistant hypertension:
- Add spironolactone with careful monitoring for hyperkalemia 7
- Chlorthalidone is effective even in stage 4 CKD and can mitigate hyperkalemia risk 7
Critical Monitoring Requirements
Within 2-4 weeks of initiating or titrating ACE inhibitor/ARB:
- Check serum creatinine and potassium 2, 3, 4
- Continue therapy unless serum creatinine rises >30% or symptomatic hypotension develops 3, 4
- Continue ACE inhibitor/ARB even when eGFR falls below 30 mL/min/1.73 m² unless discontinuation criteria are met 3, 4
Ongoing monitoring:
- Measure BP at least twice daily during hospitalization (morning and evening) 2
- Schedule clinic follow-up every 6-8 weeks until BP goal is achieved 2
- Once target BP achieved, laboratory monitoring and clinic follow-up every 3-6 months 2
Important Caveats and Pitfalls
Avoid these common errors:
- Never combine ACE inhibitor, ARB, and direct renin inhibitor together 4
- Do not use atenolol as it is less effective than placebo in reducing cardiovascular events 1
- Avoid beta blockers with intrinsic sympathomimetic activity 1
Diuretic dosing requires careful attention:
- Inadequate dosing leads to fluid retention and treatment failure 3
- Excessive dosing causes volume contraction, hypotension, and worsening renal function 3
Masked hypertension is common:
- Occurs in up to 30% of CKD patients and increases risk of CKD progression 3
- Consider home BP monitoring or 24-hour ambulatory BP monitoring when office readings appear controlled but clinical progression continues 3
During acute illness:
- Instruct patients to hold or reduce antihypertensive doses during illness with decreased oral intake, vomiting, or diarrhea to prevent volume depletion and acute kidney injury 3
Special Population: Post-Kidney Transplant
- Target BP <130/80 mmHg after kidney transplantation 1
- Calcium channel blockers are the reasonable first-line choice based on improved GFR and kidney survival (Class IIa recommendation) 1