Blood Pressure Management in Patients with Chronic Kidney Disease

First-Line Therapy Recommendations

The American College of Cardiology recommends ACEi or ARBs as first-line antihypertensive therapy for patients with high blood pressure, CKD, and severely increased albuminuria, with a strong recommendation for patients without diabetes 1, 2
The European Society of Cardiology recommends ACEi or ARBs for patients with high BP, CKD, and moderately-to-severely increased albuminuria with diabetes, with a strong recommendation 1, 2
For patients with CKD and no albuminuria, RASi may still be a reasonable treatment option, according to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline 1, 3

The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends checking changes in blood pressure, serum creatinine, and serum potassium within 2-4 weeks of initiation or dose increase of a RASi 1, 2
The American College of Cardiology recommends continuing ACEi or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation or dose increase 1, 3
The European Society of Cardiology recommends considering reducing the dose or discontinuing ACEi or ARB in cases of symptomatic hypotension, uncontrolled hyperkalemia despite treatment, or to reduce uremic symptoms in advanced kidney failure (eGFR <15 ml/min/1.73 m²) 1, 2

The American Heart Association recommends avoiding any combination of ACEi, ARB, and direct renin inhibitor therapy in patients with CKD 1, 2
RASi are contraindicated during pregnancy, according to the European Society of Cardiology 4, 5
The American College of Cardiology recommends using RASi with caution in patients with peripheral vascular disease due to association with renovascular disease 4

For kidney transplant recipients, a dihydropyridine calcium channel blocker (CCB) or an ARB is recommended as first-line antihypertensive therapy, according to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline 3, 6
In black patients, initial antihypertensive treatment should include a diuretic or a CCB, either alone or in combination with a RASi, recommends the European Society of Cardiology 7
For resistant hypertension, adding low-dose spironolactone to existing treatment is recommended, though with caution in patients with low eGFR due to hyperkalemia risk, according to the American College of Cardiology 7, 1

For adults with CKD, a target systolic BP of <120 mmHg is suggested when tolerated, recommends the Kidney Disease: Improving Global Outcomes (KDIGO) guideline 3
In patients with diabetic or non-diabetic CKD, it is recommended to lower systolic BP to a range of 130-139 mmHg, according to the European Society of Cardiology 7
For patients with moderate-to-severe CKD with eGFR >30 mL/min/1.73 m², target systolic BP should be 120-129 mmHg if tolerated, recommends the European Society of Cardiology 7

Hyperkalemia associated with RASi use can often be managed by measures to reduce serum potassium levels rather than decreasing the dose or stopping RASi, according to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline 1, 2
Mineralocorticoid receptor antagonists are effective for management of refractory hypertension but may cause hyperkalemia or reversible decline in kidney function, particularly in patients with low eGFR, recommends the American College of Cardiology 1, 3
In elderly patients with CKD, the same guidelines apply as for younger patients, provided BP-lowering treatment is well tolerated, according to the European Society of Cardiology 5
Testing for orthostatic hypotension is recommended before starting or intensifying BP-lowering medication in elderly patients, recommends the European Society of Cardiology 5

The American College of Cardiology recommends the following medication selection algorithm: