How to manage hypertension in patients with chronic kidney disease (CKD)?

Management of Hypertension in CKD Patients

Target a blood pressure of <130/80 mmHg for all adults with CKD and hypertension, using standardized office measurements, to reduce cardiovascular mortality and stroke risk. 1

Blood Pressure Targets by Patient Age

Younger Patients (<65 years)

• Aim for systolic BP <120 mmHg based on KDIGO 2021 guidelines, as this intensive target reduces cardiovascular death and stroke—the leading causes of mortality in CKD patients 1, 2
• This aggressive target is justified because CKD automatically confers ≥10% 10-year cardiovascular risk, placing all CKD patients in the high-risk category 2
• Accept that intensive BP lowering causes a small initial eGFR decline (primarily in first 6 months), but the cardiovascular and survival benefits outweigh risks of hyperkalemia and acute kidney injury 1

Older Patients (≥65 years)

• Target systolic BP 130-139 mmHg per European Society of Cardiology recommendations, as this range is safer and more appropriate than aggressive targets below 120 mmHg in this vulnerable population 2, 3
• Avoid diastolic BP <70 mmHg, which compromises coronary perfusion and increases mortality 2, 3

First-Line Pharmacological Management

Patients WITH Albuminuria

• Start an ACE inhibitor (or ARB if ACE inhibitor not tolerated) for all CKD patients with albuminuria ≥300 mg/day (or ≥300 mg/g albumin-to-creatinine ratio) 1
• This recommendation has the strongest evidence (Class I/IIa) for CKD stages 1-4 with severely increased albuminuria (A3 category), based on RCTs showing clear reduction in kidney failure and cardiovascular events 1
• For moderately increased albuminuria (30-299 mg/day, A2 category), ACE inhibitor/ARB is still reasonable but with weaker evidence 1, 2
• These agents provide renoprotection beyond BP control alone and slow CKD progression 2, 3

Patients WITHOUT Albuminuria

• Use standard first-line antihypertensive choices (thiazide/thiazide-like diuretics, calcium channel blockers, ACE inhibitors, or ARBs) 1
• The cardiovascular benefit of intensive BP control applies regardless of albuminuria status, eliminating the need for separate targets 1

Combination Therapy Strategy

Most CKD patients require multiple agents to achieve BP targets 4:

1. Second-line agent: Add a thiazide or thiazide-like diuretic (chlorthalidone preferred) if target not achieved with ACE inhibitor/ARB monotherapy 3, 5
2. Third-line agent: Add a long-acting dihydropyridine calcium channel blocker 5
3. Resistant hypertension: Add spironolactone, but monitor closely for hyperkalemia in moderate-to-advanced CKD; chlorthalidone can mitigate hyperkalemia risk when used with spironolactone 5

Critical Monitoring Parameters

• Check serum creatinine, eGFR, and potassium within 2-4 weeks after initiating or adjusting ACE inhibitor/ARB therapy 2, 3
• Continue therapy unless creatinine rises >30% within 4 weeks of initiation or dose increase—up to 30% rise is acceptable and does not require discontinuation 2, 3
• Use standardized office BP measurement technique rather than casual readings, as recommended targets apply specifically to standardized measurements 2, 3

Essential Lifestyle Modifications

• Restrict dietary sodium to <2 g/day (<90 mmol/day or <5 g sodium chloride/day), as salt restriction is particularly important in CKD and enhances RAS inhibitor effectiveness 2, 3
• This intervention is often overlooked but can significantly improve BP control 5

Critical Pitfalls to Avoid

Medication Combinations

• Never combine ACE inhibitor + ARB, as this increases adverse effects (hyperkalemia, acute kidney injury) without additional cardiovascular or renal benefits 2, 3
• Never combine ACE inhibitor or ARB with direct renin inhibitors 2, 3
• Avoid atenolol, as it is less effective than placebo in reducing cardiovascular events 1

Blood Pressure Management

• Do not allow diastolic BP to fall below 70 mmHg, which compromises coronary perfusion and increases mortality 2, 3
• Do not abruptly discontinue all antihypertensives without a stepwise approach, even in hypotensive patients 6

Monitoring Errors

• Do not use casual BP readings to guide therapy—use standardized office measurements or consider ambulatory/home BP monitoring 2, 3
• Be cautious with potassium-rich salt substitutes or DASH diet in advanced CKD due to hyperkalemia risk 3

Special Populations

Post-Kidney Transplant

• Target BP <130/80 mmHg is reasonable 1
• Consider calcium channel blockers as they improve GFR and kidney survival in this population 1

Dialysis Patients

• Target predialysis BP 140/90 mmHg (sitting position) provided no substantial orthostatic hypotension 6
• Assess and achieve appropriate dry weight while avoiding excessive ultrafiltration that precipitates hypotension 6