What medications are recommended for a patient with Chronic Kidney Disease (CKD) and hypertension?

Medication Management for CKD with Hypertension

For patients with CKD and hypertension, start an ACE inhibitor or ARB immediately and titrate to the maximum approved dose, target blood pressure <130/80 mmHg, add an SGLT2 inhibitor if diabetic (regardless of glucose control), and initiate statin therapy for all patients. 1, 2

Blood Pressure Management

Target Blood Pressure

• Aim for BP <130/80 mmHg for all CKD patients with hypertension 1, 2
• For patients with severely elevated albuminuria (≥300 mg/g), consider targeting systolic BP 120-129 mmHg 2

First-Line Antihypertensive Therapy

ACE Inhibitors or ARBs are mandatory first-line agents for CKD patients with albuminuria (≥30 mg/g) and hypertension:

• Titrate to the highest approved tolerated dose (Grade 1B recommendation) 1, 2
• For losartan specifically: start 50 mg daily, increase to 100 mg daily as needed for BP control 3
• Start with 25 mg if volume depleted or on diuretics 3

Monitoring after ACE inhibitor/ARB initiation is critical:

• Check serum creatinine and potassium within 2-4 weeks of starting or dose changes 1
• Continue therapy unless creatinine rises >30% within 4 weeks 1
• If creatinine increases >30%, evaluate for acute kidney injury, volume depletion, renal artery stenosis, and review NSAIDs/diuretics before stopping 1

Managing Hyperkalemia

Do not immediately stop ACE inhibitors/ARBs for hyperkalemia - instead implement these strategies first: 1

• Review and stop concurrent potassium-raising medications
• Moderate dietary potassium intake
• Add diuretics if not contraindicated
• Consider sodium bicarbonate supplementation
• Use GI cation exchangers
• Only reduce dose or discontinue as last resort 1

Additional Antihypertensive Agents

When ACE inhibitor/ARB alone is insufficient:

• Add long-acting dihydropyridine calcium channel blockers (CCBs) as second-line 4, 5
• Add thiazide or loop diuretics as third-line 2, 4
• Most CKD patients require 3+ antihypertensive agents to reach target BP 1

For treatment-resistant hypertension:

• Add spironolactone (steroidal mineralocorticoid receptor antagonist) 5
• Alternative: chlorthalidone is effective in stage 4 CKD and can mitigate hyperkalemia risk 5
• Monitor potassium closely with these combinations 5

Important caveat: Non-dihydropyridine CCBs (verapamil, diltiazem) are contraindicated in heart failure with reduced ejection fraction 1

Glucose-Lowering Medications (Type 2 Diabetes)

SGLT2 inhibitors are now mandatory for all type 2 diabetics with CKD stage 3 or higher (eGFR <60 mL/min/1.73 m²):

• Initiate regardless of glycemic control - the benefit is for kidney and cardiovascular protection, not glucose lowering 1, 2, 6
• Start when eGFR ≥20 mL/min/1.73 m² 1
• Continue until dialysis or transplantation - benefits persist as eGFR declines 1, 2
• Combine with metformin when eGFR ≥30 mL/min/1.73 m² 1, 2

If additional glucose lowering needed beyond SGLT2 inhibitor + metformin:

• Add GLP-1 receptor agonist as preferred third agent 1, 2
• GLP-1 agonists reduce risk of end-stage kidney disease 7

For patients with persistent albuminuria >30 mg/g despite first-line therapy:

• Consider adding nonsteroidal mineralocorticoid receptor antagonist (finerenone) for additional kidney and cardiovascular protection 1

Lipid Management

Initiate statin therapy for ALL CKD patients - this is non-negotiable: 1, 2

• Cardiovascular disease is the leading cause of death in CKD 2
• Add ezetimibe, PCSK9 inhibitor, or icosapent ethyl based on residual ASCVD risk and lipid levels 1

Additional Medications and Monitoring

Sodium bicarbonate supplementation:

• Give oral bicarbonate if serum bicarbonate <22 mmol/L to maintain normal range (Grade 2B) 1

Antiplatelet therapy:

• Aspirin for lifelong secondary prevention in established cardiovascular disease 1
• May consider for primary prevention in high-risk individuals 1

Avoid nephrotoxic medications:

• NSAIDs (including COX-2 inhibitors) 1
• Aminoglycosides, amphotericin B 1
• High-osmolar contrast agents - use lowest dose, ensure hydration 1

Lifestyle Modifications

Dietary sodium restriction is critical and often overlooked:

• Limit to <2 g/day sodium (5 g salt) 1, 2, 5
• This enhances effectiveness of RAS blockade 2, 5

Protein intake:

• Restrict to 0.8 g/kg/day when eGFR <30 mL/min/1.73 m² 1, 2
• Avoid high protein intake >1.3 g/kg/day 1, 2
• Do not restrict if malnourished 1

Mandatory interventions:

• Smoking cessation - tobacco accelerates CKD progression 2
• Regular exercise for BP control and cardiovascular outcomes 2

Follow-Up Monitoring Schedule

Intensive monitoring when:

• Systolic BP ≥140 or <120 mmHg: recheck within 4 weeks 1
• eGFR <60 mL/min/1.73 m²: recheck within 4 weeks 1
• On ACE inhibitor/ARB with potassium >4.5 mEq/L: recheck within 4 weeks 1

Once stable:

• Reassess risk factors every 3-6 months 1
• Monitor eGFR every 1-6 months if <60 mL/min/1.73 m² or declining ≥4 mL/min/1.73 m²/year 1