What is the recommended management of hypertension in an adult with end‑stage renal disease (chronic kidney disease stage 5, eGFR < 15 mL/min/1.73 m²) and a mean arterial pressure of 133 mmHg?

Hypertension Management in CKD Stage 5 with MAP 133 mmHg

Blood Pressure Target

Target a systolic blood pressure <130/80 mmHg using standardized office measurement in this patient with end-stage renal disease. 1, 2, 3 A mean arterial pressure of 133 mmHg corresponds to approximately 177/110 mmHg (assuming typical pulse pressure), which is severely elevated and requires aggressive treatment. 3

• An alternative acceptable systolic range of 130-139 mmHg may be considered if the patient cannot tolerate more intensive lowering. 3
• The <120 mmHg systolic target should only be applied when using standardized automated office measurement (5-minute rest, average of three readings); applying this to routine office readings leads to overtreatment. 1, 2, 3

First-Line Pharmacologic Therapy

Initiate or continue an ACE inhibitor (such as lisinopril 10 mg daily) or ARB as the cornerstone of therapy, titrating to the maximum tolerated dose. 1, 3 In CKD Stage 5, the FDA-approved starting dose of lisinopril is 2.5 mg once daily for patients on hemodialysis or with creatinine clearance <10 mL/min, with uptitration to a maximum of 40 mg daily as tolerated. 4

• ACE inhibitors or ARBs should be administered at the highest approved dose that the patient can tolerate, as trial benefits were achieved at these target doses. 1, 3
• Check serum creatinine and potassium within 2-4 weeks of initiation or dose increase. 1, 3
• Continue therapy if creatinine rises ≤30% within 4 weeks, as this reflects hemodynamic changes and does not indicate harm. 3

Critical Monitoring Caveat

However, in CKD Stage 5, consider reducing the dose or discontinuing ACE inhibitors/ARBs if the patient develops symptomatic hypotension, uncontrolled hyperkalemia despite medical treatment, or worsening uremic symptoms. 3 This is a unique consideration for end-stage renal disease that does not apply to earlier CKD stages.

Second-Line Therapy: Loop Diuretics

Add a loop diuretic (furosemide 40-80 mg daily or equivalent) as the mandatory second agent in CKD Stage 5. 3 Thiazide diuretics are ineffective when GFR <30 mL/min or serum creatinine >2.0 mg/dL and should not be used as monotherapy in Stage 5 CKD. 3

• Loop diuretics are essential for volume management and blood pressure control in end-stage renal disease. 3
• Dietary sodium restriction to <2.0 g/day (<90 mmol/day) enhances diuretic efficacy. 3

Third-Line Therapy: Calcium Channel Blocker

Add a long-acting dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily or nifedipine extended-release 30-60 mg daily) as the third agent. 1, 3

• The typical multi-drug regimen in CKD Stage 5 consists of ACE inhibitor or ARB + loop diuretic + dihydropyridine calcium channel blocker. 3
• Most patients with end-stage renal disease require three or more antihypertensive agents to achieve target blood pressure. 2

Management of Hyperkalemia

Manage hyperkalemia associated with ACE inhibitor/ARB use through measures to reduce serum potassium levels rather than decreasing the dose or stopping the RAS inhibitor. 1, 3

• Strategies include dietary potassium restriction, loop diuretics (which provide potassium-wasting effects), or potassium binders (sodium polystyrene sulfonate or newer agents like patiromer or sodium zirconium cyclosilicate). 1
• Only discontinue the ACE inhibitor/ARB if hyperkalemia remains uncontrolled despite these interventions. 3

Critical Contraindications

Never combine ACE inhibitor + ARB, as dual RAS blockade increases the risk of hyperkalemia, hypotension, and acute kidney injury without added benefit. 1, 2, 3 This is a Class III contraindication with strong evidence. 2

• Do not add a direct renin inhibitor to an ACE inhibitor or ARB. 1, 3

Non-Pharmacological Management

Restrict dietary sodium to <2.0-2.3 g/day (<90 mmol/day) to enhance diuretic efficacy and blood pressure control. 1, 3

• Restrict protein intake to approximately 0.8 g/kg/day for CKD Stage 5 to reduce uremic symptoms while maintaining nutrition. 2
• Encourage tobacco cessation. 1, 2

Monitoring Schedule

Schedule clinic visits every 6-8 weeks until the blood pressure target is achieved, then every 3-6 months thereafter. 2

• Monitor serum creatinine, eGFR, and potassium at each visit, particularly after medication adjustments. 2
• Assess for symptoms of hypotension (fatigue, light-headedness, dizziness) at every encounter. 2
• Implement home blood pressure monitoring to prevent excessive lowering (systolic <110 mmHg). 2

Patient Education: Sick-Day Management

Instruct the patient to hold or reduce antihypertensive doses during acute illnesses with vomiting, diarrhea, or reduced oral intake to prevent volume depletion and acute kidney injury. 1, 2

Common Pitfalls to Avoid

• Do not stop ACE inhibitor/ARB for modest creatinine increases up to 30%. 3
• Do not use thiazide diuretics as monotherapy in Stage 5 CKD, as they are ineffective. 3
• Do not apply intensive BP targets (<120 mmHg) to non-standardized BP measurements. 3
• Do not withhold appropriate blood pressure control based solely on eGFR <15 mL/min/1.73 m², as cardiovascular risk remains elevated and requires treatment. 5