What is the best initial antihypertensive therapy for an elderly male with CKD (Chronic Kidney Disease) and impaired renal function, presenting with uncontrolled hypertension?

Initial Antihypertensive Management for Elderly Male with CKD Stage 3b and Uncontrolled Hypertension

Start with an ACE inhibitor (lisinopril 5 mg daily) as first-line therapy, with close monitoring of creatinine and potassium within 1-2 weeks. 1, 2

Blood Pressure Target

Your patient requires treatment to a target of <130/80 mmHg based on current guidelines for CKD patients. 3, 1, 2 With a creatinine of 3.8 mg/dL (indicating CKD stage 3b), this patient has substantially elevated cardiovascular risk and qualifies for intensive BP control. 1, 2

First-Line Medication Selection

ACE Inhibitor as Initial Therapy

• Lisinopril 5 mg once daily is the recommended starting dose for elderly patients with CKD and creatinine clearance ≥10-30 mL/min. 4
• ACE inhibitors are preferred as first-line agents for all patients with CKD stage 3 or higher, regardless of albuminuria status. 1
• The renoprotective and cardiovascular benefits extend to frail elderly patients ≥75 years with CKD based on SPRINT data. 1

Critical Monitoring After Initiation

• Check serum creatinine and potassium within 1-2 weeks of starting the ACE inhibitor, then with each dose increase, and at least yearly thereafter. 1
• A 10-25% increase in creatinine is acceptable and reflects hemodynamic effects on intraglomerular pressure—this is generally reversible and does not require discontinuation. 1, 2
• Creatinine increases >30% warrant investigation for volume depletion, nephrotoxic agents, or renovascular disease. 1

When to Add Second-Line Therapy

If BP remains >130/80 mmHg on maximally tolerated ACE inhibitor monotherapy, add one of the following: 1, 2

Option 1: Thiazide-Like Diuretic

• Chlorthalidone 12.5 mg daily is preferred over hydrochlorothiazide for its superior mortality benefit. 2
• Thiazide-like diuretics remain effective even with moderate renal impairment (eGFR >30 mL/min). 1, 2
• Monitor sodium levels weekly for the first month due to hyponatremia risk in elderly patients. 2

Option 2: Dihydropyridine Calcium Channel Blocker

• Amlodipine 2.5-5 mg daily is appropriate for elderly patients, with gradual titration as needed. 5, 2
• Calcium channel blockers combined with ACE inhibitors may slow CKD progression more effectively than ACE inhibitors combined with diuretics based on post hoc trial analysis. 3
• Watch for peripheral edema, which occurs more frequently in elderly patients and may require dose adjustment. 5

Important Caveats and Pitfalls

Volume Status and Diuretics

• Treatment resistance in CKD is largely related to sodium and fluid retention with intravascular volume expansion. 3
• Most CKD patients require 3 or more antihypertensive agents to achieve BP control. 3

What NOT to Do

• Never combine an ACE inhibitor with an ARB—this increases hyperkalemia and hypotension without additional benefit. 1, 5
• Avoid aggressive dual therapy initiation; use a gradual, stepped-care approach in elderly patients to minimize adverse events. 2

Orthostatic Hypotension Screening

• Always measure BP in both sitting and standing positions in elderly patients to assess for orthostatic hypotension. 2
• Regularly inquire about postural dizziness when treating elderly CKD patients with BP-lowering drugs. 3

If ACE Inhibitor Not Tolerated

• Switch to an ARB (losartan 25 mg daily), which has been shown to be noninferior to ACE inhibitors. 1, 2
• ARBs are particularly important if albuminuria is present. 1

Monitoring Schedule

• Week 1-2: Creatinine, potassium, BP (sitting and standing) 1, 2
• Week 4: Reassess BP control and symptoms 2
• Every 3-6 months: Creatinine, potassium, BP depending on stability 5
• Yearly: Comprehensive reassessment if stable 1