Hypertension Management

Treatment Optimization

• When the blood pressure target is not achieved with maximum tolerated doses of current medications, the American Heart Association recommends adding a dihydropyridine calcium channel blocker (e.g., amlodipine) 1
• The American Diabetes Association suggests considering the addition of a mineralocorticoid receptor antagonist (e.g., spironolactone) if potassium levels allow 2
• The European Society of Hypertension emphasizes the importance of uptitrating antihypertensive medications to maximum tolerated doses to achieve blood pressure targets 1

Medication Management in Chronic Kidney Disease (CKD)

• ACE inhibitors or ARBs are the preferred first-line antihypertensive medications for patients with CKD, especially those with albuminuria, due to their proven benefits in slowing CKD progression beyond blood pressure control alone, as recommended by the American Diabetes Association, Kidney International, and supported by 3, 4, 5.
• Target blood pressure <130/80 mmHg for all CKD patients to reduce cardiovascular mortality and slow CKD progression, as recommended by the American Diabetes Association 3, and also supported by the American Heart Association 6.
• Consider lower targets for patients with severely elevated albuminuria (≥300 mg/g creatinine), according to the American Diabetes Association 3.
• The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 guideline suggests a systolic blood pressure target of <120 mmHg when tolerated, based on standardized office blood pressure measurement, for patients with CKD, with a high strength of evidence 4, 7.

Renin-Angiotensin System Inhibitors (RASi) and ACE Inhibitors (ACEi)

• ACE inhibitors and ARBs provide renoprotection through reducing intraglomerular pressure, decreasing proteinuria, slowing GFR decline, and reducing risk of progression to end-stage kidney disease (ESKD), as reported by the American Diabetes Association and Kidney International 3, 5.
• Renin-angiotensin system inhibitors (ACEi or ARB) should be first-line therapy, especially with albuminuria, due to their renal protective effects, as recommended by the Kidney International guideline and the American Heart Association 7, 6.
• Avoid dual RAS blockade, as combined use of ACE inhibitors and ARBs should be avoided due to increased risk of adverse events (hyperkalemia, acute kidney injury) without additional benefits, according to the American Diabetes Association 8.

Lifestyle Modifications

• Lifestyle modifications such as sodium restriction, regular physical activity, weight loss, and DASH diet are important alongside pharmacological therapy for CKD patients, as generally recommended by various health organizations, including the American Heart Association 6, and the American Journal of Kidney Diseases 9.
• The Kidney International guideline recommends sodium restriction to <2g sodium per day (<5g sodium chloride) 7, 4, 10.
• The Kidney International guideline suggests at least 150 minutes per week of moderate-intensity physical activity 7, 4, 10.
• Weight loss is recommended for overweight or obese patients with CKD, as part of a comprehensive management plan, according to the American Journal of Kidney Diseases 9.
• The DASH diet is recommended for all CKD patients with hypertension, as a lifestyle modification to support blood pressure control, as suggested by the American Journal of Kidney Diseases 9.

Monitoring and Follow-up

• The KDIGO guidelines recommend blood pressure monitoring once yearly with ABPM and every 3-6 months with standardized auscultatory office blood pressure 7.
• The following monitoring is recommended:

• The Kidney International guideline recommends monitoring serum creatinine and potassium within 2-4 weeks after initiation or dose increase of RASi or ACEIs/ARBs 7, 9.
• The following monitoring is recommended:

Additional Therapies

• Diuretics are essential for volume control in CKD, with thiazide-like diuretics preferred for eGFR >30 ml/min/1.73m² and loop diuretics for eGFR <30 ml/min/1.73m² or volume overload, as stated by the American Journal of Kidney Diseases and the Kidney International guideline 11, 9, 12.
• The Kidney International guideline recommends dihydropyridine CCBs as first-line agents in kidney transplant recipients and as effective add-on therapy for CKD patients not at target BP with RASi alone 7.
• The Kidney International guideline recommends using loop diuretics as preferred agents for ESRD patients with volume overload, with a high strength of evidence 7.
• Finerenone has shown kidney and cardiovascular protection in diabetic CKD, with a moderate strength of evidence 13, 4.
• The Diabetes Care guideline recommends adding MRAs, such as spironolactone, eplerenone, or finerenone, for resistant hypertension in CKD patients, particularly in combination with ACEi/ARB for proteinuric CKD 14.
• The American Journal of Kidney Diseases recommends using hydralazine or minoxidil for severe resistant hypertension in CKD patients 15.

Management of Hyperkalemia

• The Kidney International guideline recommends implementing measures to reduce serum potassium rather than immediately reducing RASi dose, with a moderate strength of evidence 7.
• The Diabetes Care guideline suggests monitoring potassium levels closely, especially with MRAs, with a moderate strength of evidence 13.
• The KDIGO guidelines recommend careful monitoring for hyperkalemia when using MRAs, especially in advanced CKD 7.