Initial Treatment for Hypertension in Patients with Chronic Kidney Disease (CKD)

Blood Pressure Targets in CKD

The European Society of Cardiology recommends that adults with hypertension and CKD should be treated to a BP goal of less than 130/80 mm Hg 3, 4, 5
For patients with moderate-to-severe CKD with eGFR >30 mL/min/1.73 m², a systolic BP target of 120-129 mm Hg is recommended if tolerated 3
For patients with lower eGFR or kidney transplantation, individualized BP targets are recommended based on tolerability and impact on renal function and electrolytes 3

The Kidney International guideline recommends that ACE inhibitors or ARBs are strongly recommended for severely increased albuminuria (A3) without diabetes (Class 1B recommendation) 1, 2
The Kidney International guideline suggests that ACE inhibitors or ARBs are suggested for moderately increased albuminuria (A2) without diabetes (Class 2C recommendation) 1, 2
The Kidney International guideline recommends that ACE inhibitors or ARBs are strongly recommended for moderately-to-severely increased albuminuria (A2 and A3) with diabetes (Class 1B recommendation) 1, 2

RASi should be administered at the highest approved dose that is tolerated to achieve maximum benefits 1, 2
Monitor changes in BP, serum creatinine, and serum potassium within 2-4 weeks of initiation or dose increase 1, 2
Continue ACE inhibitor or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation or dose increase 1, 2

Avoid any combination of ACE inhibitor, ARB, and direct renin inhibitor therapy in patients with CKD (Class 1B recommendation) 1, 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 kidney failure (eGFR <15 ml/min per 1.73 m²) 1, 2
For black patients with CKD, initial antihypertensive treatment should include a diuretic or a calcium channel blocker, either in combination or with a RAS blocker 3

Inadequate dosing of diuretics can result in fluid retention, while excessive doses may lead to volume contraction, increasing the risk of hypotension and renal insufficiency 4