Management of Uncontrolled Hypertension in CKD Patients

Rationale for Adding an ACE Inhibitor or ARB

• The International Society of Hypertension guidelines recommend an ACE inhibitor or ARB as a core component of antihypertensive therapy in patients with CKD, due to their renoprotective effects beyond blood pressure lowering 1, 3
• For patients with hypertension who are not meeting blood pressure targets on two classes of antihypertensive medications, adding a third class, such as an ACE inhibitor or ARB, is recommended 3

Medication Selection Considerations

• ACE inhibitors and ARBs are specifically recommended for patients with CKD due to their renoprotective effects beyond blood pressure lowering 3
• Monitor renal function and potassium levels after initiating therapy with an ACE inhibitor or ARB, as they can cause acute kidney injury or hyperkalemia in some patients 3

If Target BP Still Not Achieved

• If blood pressure remains uncontrolled after adding an ACE inhibitor or ARB, the next step would be to add a mineralocorticoid receptor antagonist, such as spironolactone, to achieve target blood pressure 3
• Alternative fourth-line options include eplerenone, amiloride, or doxazosin if spironolactone is not tolerated 1

Monitoring Recommendations

• Check blood pressure within 3 months of medication changes to assess efficacy, and monitor renal function and electrolytes within 1-2 weeks of starting an ACE inhibitor or ARB 1, 3
• Target blood pressure for CKD patients should be <130/80 mmHg according to current guidelines, such as those from the American Heart Association 2

Important Cautions

• Never combine an ACE inhibitor with an ARB as this combination increases adverse effects without providing additional cardiovascular benefit, as recommended by the American College of Cardiology 3
• Ensure patient adherence to all medications before adding new agents, as recommended by the International Society of Hypertension 2