Blood Pressure Management in Chronic Kidney Disease

First-Line Therapy Selection

The American Diabetes Association recommends ACE inhibitors or ARBs as first-line therapy for hypertension in CKD patients, especially those with albuminuria ≥300 mg/g creatinine, due to their proven benefits in slowing CKD progression and reducing cardiovascular events 1, 2
ACE inhibitors and ARBs are considered to have similar benefits and risks in CKD patients and can be used interchangeably based on tolerability, with a strength of evidence level of high 1, 3
The highest approved dose of ACE inhibitors or ARBs that is tolerated should be administered to achieve maximum renoprotective benefits in CKD patients 2
For patients with diabetes and CKD with albuminuria ≥30 mg/g creatinine, ACE inhibitors or ARBs are particularly recommended by the American Diabetes Association, with a strength of evidence level of moderate 3, 4

The European Society of Cardiology recommends a blood pressure target of <130/80 mmHg for most CKD patients to reduce cardiovascular mortality and slow CKD progression, with a strength of evidence level of high 1, 5
In adults with moderate-to-severe CKD who have eGFR >30 mL/min/1.73 m², a systolic BP target of 120-129 mmHg is recommended if tolerated by the European Society of Cardiology, with a strength of evidence level of moderate 5
Lower blood pressure goals may be suitable for individuals with severely elevated albuminuria (≥300 mg/g creatinine), as recommended by the American Diabetes Association, with a strength of evidence level of low 1

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend checking changes in blood pressure, serum creatinine, and serum potassium within 2-4 weeks of initiation or dose increase of an ACE inhibitor or ARB in CKD patients, with a strength of evidence level of high 2
Continue ACE inhibitor or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation or dose increase, as recommended by KDIGO, with a strength of evidence level of moderate 2
Consider reducing the dose or discontinuing ACE inhibitor or ARB in cases of symptomatic hypotension, uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms in advanced kidney failure (eGFR <15 ml/min/1.73 m²), as recommended by KDIGO, with a strength of evidence level of low 2

For kidney transplant recipients, a dihydropyridine CCB or an ARB is recommended as the first-line antihypertensive agent by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, with a strength of evidence level of moderate 2
Mineralocorticoid receptor antagonists (spironolactone, eplerenone) can be effective for management of refractory hypertension but may cause hyperkalemia, particularly in patients with low eGFR, as noted by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, with a strength of evidence level of low 2

Avoid any combination of ACE inhibitor, ARB, and direct renin inhibitor therapy in patients with CKD, as this increases risk of adverse effects without additional benefits, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, with a strength of evidence level of high 2
Hyperkalemia associated with ACE inhibitors or ARBs can often be managed by measures to reduce serum potassium levels rather than decreasing the dose or stopping the medication, as noted by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, with a strength of evidence level of moderate 2
In patients with CKD and diabetes, SGLT2 inhibitors should be considered as part of the treatment regimen due to their renoprotective effects beyond glucose control, as recommended by the American Diabetes Association and the European Society of Cardiology, with a strength of evidence level of high 1, 5
For patients with CKD stage 3 or higher, medication dosing may require modification when eGFR is <60 mL/min/1.73 m², as recommended by the American Diabetes Association, with a strength of evidence level of moderate 1

In children with CKD, ACE inhibitors or ARBs should be used as first-line therapy for high blood pressure, with monitoring for hyperkalemia and adverse effects, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, with a strength of evidence level of moderate 2
In black patients with hypertension, initial antihypertensive treatment should include a diuretic or a calcium channel blocker, either alone or in combination with a RAAS blocker, as recommended by the European Society of Cardiology, with a strength of evidence level of moderate 6
For elderly CKD patients, the same guidelines apply as for younger people, provided BP-lowering treatment is well tolerated, with careful monitoring for orthostatic hypotension, as recommended by the European Society of Cardiology, with a strength of evidence level of low 5