Management of Severe Hypertension in CKD Stage 5

Target Blood Pressure

• The American College of Cardiology recommends a primary target blood pressure of SBP 130-139 mmHg, which is acceptable and safe in CKD Stage 5 patients 1, 2
• The American College of Cardiology also suggests an intensive target of SBP <120 mmHg may be considered if tolerated, based on SPRINT trial benefits for cardiovascular outcomes, though this must use standardized office BP measurement 1, 2, 3

Transition to Chronic Oral Therapy

• The American Heart Association recommends continuing metoprolol 25 mg twice daily, and adding or optimizing ACE inhibitor or ARB at maximal tolerated dose if not contraindicated by hyperkalemia or symptomatic hypotension 1, 2, 4, 5
• The National Kidney Foundation suggests adding a loop diuretic, such as furosemide 40-80 mg twice daily or torsemide 10-20 mg daily, as thiazides are ineffective at GFR <30 mL/min 2, 4

Critical Monitoring During Transition

• The Annals of Internal Medicine recommends checking serum creatinine and potassium within 2-4 weeks of initiating or increasing ACE inhibitor/ARB dose 2, 5
• The Journal of the American College of Cardiology suggests continuing ACE inhibitor/ARB if creatinine rises ≤30% from baseline, as this reflects hemodynamic changes rather than harm 2, 3, 5

Common Pitfalls to Avoid

• The Journal of the American College of Cardiology advises against combining ACE inhibitor + ARB, as it increases adverse events without benefit 2, 3, 5
• The American College of Cardiology recommends not discontinuing RAS inhibitor for modest creatinine increases, as up to 30% increase is acceptable and expected 1, 2, 3, 5