Managing Hypertension in Chronic Kidney Disease

Blood Pressure Target

The American College of Cardiology recommends that all adults with hypertension and chronic kidney disease should be treated to a blood pressure goal of less than 130/80 mmHg, with strong evidence for the systolic target, regardless of CKD stage or albuminuria status 1, 2, 3
The SPRINT trial demonstrated that intensive BP management to this lower target provides the same cardiovascular and mortality benefits seen in the overall study population, including 28% of participants with stage 3-4 CKD 3
This target applies to all CKD stages, with the vast majority of CKD patients having a 10-year ASCVD risk ≥10%, placing them in the high-risk category requiring treatment initiation at BP ≥130/80 mmHg 4

The American College of Cardiology recommends that in adults with CKD stage 3 or higher, or stage 1-2 with albuminuria ≥300 mg/day, an ACE inhibitor is the reasonable first-line choice to slow kidney disease progression, with a Class IIa recommendation 1, 2, 3
If an ACE inhibitor is not tolerated, an ARB may be reasonable as an alternative, with a Class IIb recommendation 1, 2, 3

The AHA/ACC provides a clear decision tree, including assessing albuminuria status and starting ACE inhibitors for those with albuminuria ≥300 mg/day, and using usual first-line medication choices for those with albuminuria <300 mg/day 1, 4
Titrate to BP goal <130/80 mmHg using additional agents as needed 1, 2

After initiating or titrating ACE inhibitors/ARBs, check serum creatinine and potassium within 2-4 weeks, and continue therapy unless serum creatinine rises >30% or symptomatic hypotension develops 4, 5
Continue ACE inhibitor/ARB even when eGFR falls below 30 mL/min/1.73 m² unless discontinuation criteria are met 5

The American College of Cardiology recommends treating to BP goal <130/80 mmHg, with a calcium channel blocker as the reasonable first-line choice based on improved GFR and kidney survival, with a Class IIa recommendation 1, 6

Start ACE inhibitors/ARBs at low doses and titrate to the highest approved dose that is tolerated, as proven benefits in trials were achieved using these target doses 5

Diuretics require careful dosing to avoid fluid retention and treatment failure, or volume contraction, hypotension, and worsening renal function 2, 6
Masked hypertension occurs in up to 30% of CKD patients and increases risk of CKD progression, and consider home BP monitoring or ambulatory BP monitoring when office readings seem controlled but clinical progression continues 3
Instruct patients to hold or reduce antihypertensive doses during illness with decreased oral intake, vomiting, or diarrhea to prevent volume depletion and acute kidney injury 4