Uncontrolled Hypertension Management in CKD Stage 3B

Direct Recommendation

• The American College of Cardiology recommends optimizing the current regimen by increasing lisinopril to 20-40 mg daily and maximizing furosemide to 40-80 mg twice daily before adding hydralazine in patients with CKD stage 3B, African American ethnicity, and suboptimal dosing of existing medications 1

Rationale for Dose Optimization Over Adding Hydralazine

• The blood pressure of 190/100 mmHg represents stage 2 hypertension requiring immediate intensification, according to Hypertension guidelines 2

Specific Medication Adjustments

• The American College of Cardiology suggests increasing lisinopril from 10 mg to 20 mg initially, with potential titration to 40 mg daily in patients with CKD stage 3B 1
• Loop diuretics, such as furosemide, are preferred over thiazides in moderate-to-severe CKD, and the dose should be increased to 40-80 mg twice daily in patients with CKD 3B 1

Stepwise Approach for This Patient

• The American College of Cardiology recommends a stepwise approach, starting with increasing lisinopril to 20 mg daily and furosemide to 40 mg twice daily, and continuing amlodipine 10 mg and carvedilol 12.5 mg twice daily 1
• If blood pressure remains uncontrolled, consider adding spironolactone 25-50 mg daily as the preferred fourth agent in resistant hypertension, as recommended by the American College of Cardiology and Hypertension guidelines 1, 2

Special Considerations for African American Patients with CKD

• The American Journal of Kidney Diseases recommends the combination of ACE inhibitor + CCB + loop diuretic as appropriate for African American patients with CKD 4