What are the recommended antihypertensive drugs for patients with Chronic Kidney Disease (CKD)?

From the Guidelines

For patients with chronic kidney disease (CKD), angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are the first-line antihypertensive medications, as recommended by the KDIGO 2021 clinical practice guideline 1.

Key Considerations

• The target systolic blood pressure (SBP) for CKD patients is <120 mm Hg, as measured using standardized office BP, to achieve cardioprotective and survival benefits 1.
• ACEIs and ARBs are preferred because they not only lower blood pressure but also reduce proteinuria and slow CKD progression by decreasing intraglomerular pressure.
• Common ACEIs include lisinopril (10-40 mg daily), enalapril (5-40 mg daily in divided doses), or ramipril (2.5-20 mg daily), while ARB options include losartan (25-100 mg daily), valsartan (80-320 mg daily), or irbesartan (150-300 mg daily) 1.

Treatment Approach

• Start with an ACEI or ARB, and monitor kidney function and potassium levels within 1-2 weeks, as they can cause acute kidney injury or hyperkalemia in some patients.
• If blood pressure targets aren't achieved with an ACEI or ARB alone, a calcium channel blocker like amlodipine (5-10 mg daily) or a thiazide-like diuretic such as chlorthalidone (12.5-25 mg daily) can be added.
• For advanced CKD (stages 4-5), loop diuretics like furosemide (20-80 mg once or twice daily) may be needed instead of thiazides.

Important Safety Considerations

• Never combine ACEIs with ARBs as this increases adverse effects without additional benefit, as recommended by the KDIGO 2021 clinical practice guideline 1.
• Dose adjustments may be necessary as kidney function declines, particularly for medications that are primarily renally cleared.

From the Research

Hypertension Drugs for CKD

• The treatment of hypertension in patients with chronic kidney disease (CKD) is crucial to slow the progression of the disease and reduce the risk of cardiovascular events 2, 3, 4.
• The recommended blood pressure goal for CKD patients is <130/80 mmHg, which often requires lifestyle modifications and multiple antihypertensive medications 2, 4.
• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are recommended as first-line treatments for CKD patients with hypertension, due to their renoprotective and cardioprotective effects 2, 4, 5, 6.
• Non-dihydropyridine calcium channel blockers (CCBs) can reduce albuminuria and slow the decline in kidney function, while dihydropyridine CCBs should not be used as monotherapy in proteinuric CKD patients 2.
• Diuretics are commonly used in the management of CKD patients and represent a cornerstone in their treatment 2, 4.
• Other antihypertensive agents, such as beta-blockers, alpha-blockers, and vasodilators, may be used in combination with ACE inhibitors, ARBs, or CCBs to achieve blood pressure goals 4.
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors, which are anti-diabetic drugs, have been shown to have a positive impact on heart and kidney complications in CKD patients 5.
• The use of ACE inhibitors and ARBs has been associated with lower risk of heart failure and death in CKD patients, regardless of the severity of the disease 6.