Management of Hypertension with Impaired Renal Function

Assessment of Renal Status

The European Society of Cardiology recommends that a patient with an eGFR of 62 ml/min/1.73m² be classified as having Stage 2 chronic kidney disease (CKD), with a range of 60-89 ml/min/1.73m² defining Stage 2 1, 2
The presence of significant proteinuria, as indicated by a urine creatinine ratio of 87.2 mg/mmol, is a marker of kidney damage and glomerular filtration barrier derangement, according to the European Heart Journal 1, 2
The combination of reduced eGFR and proteinuria indicates a greater risk of cardiovascular and renal events than either abnormality alone, as stated by the European Heart Journal 2

The American Diabetes Association, as published in Diabetes Care, recommends starting with an ACE inhibitor or ARB as first-line therapy due to the presence of significant proteinuria 3
The European Heart Journal suggests that ARBs/ACEIs have been shown to reduce the rate of progression of renal disease as measured by doubling of serum creatinine or progression to end-stage renal disease 4, 2
If blood pressure remains ≥150/90 mmHg, the American College of Cardiology recommends considering initial treatment with two antihypertensive medications to more effectively achieve blood pressure control 3
The American College of Cardiology suggests adding a thiazide-like diuretic (chlorthalidone or indapamide preferred) if additional medication is needed 3, 5

The European Society of Cardiology recommends a target blood pressure of <130/80 mmHg if tolerated, but not <120 mmHg systolic, as published in the European Heart Journal 4
Regular monitoring of blood pressure is essential to ensure targets are being met, according to Diabetes Care 3

The American Diabetes Association recommends monitoring serum creatinine and potassium within 7-14 days after initiation of ACE inhibitor or ARB therapy, as published in Diabetes Care 3
A slight increase (up to 20%) in serum creatinine may occur when antihypertensive therapy with RAS blockers is initiated but should not be taken as a sign of progressive renal deterioration, according to the European Heart Journal 2

The European Society of Cardiology recommends dietary sodium restriction to enhance the effectiveness of antihypertensive medications, as published in the European Heart Journal 6
Weight loss is recommended if indicated (BMI >25), according to the European Heart Journal 6
Regular physical activity (at least 150 minutes per week of moderate-intensity activity) is suggested, as published in the European Heart Journal 6

The European Society of Cardiology recommends considering adding a mineralocorticoid receptor antagonist (spironolactone) at low dose if blood pressure remains uncontrolled despite three medications including a diuretic, as published in the European Heart Journal 6
Monitor potassium closely when using spironolactone, especially in the setting of reduced renal function, according to the European Heart Journal 6

The presence of both reduced eGFR and proteinuria indicates a higher risk profile requiring more aggressive management, as stated by the European Heart Journal 2

The American College of Cardiology recommends a target blood pressure of <130/80 mmHg for patients with stage 3-4 CKD, based on SPRINT trial data showing cardiovascular and mortality benefits 7, 8
The American Heart Association establishes <130/80 mmHg as the goal for all CKD patients, based on SPRINT trial data showing cardiovascular and mortality benefits 7, 8

The American College of Cardiology recommends starting with an ACE inhibitor (or ARB if ACE inhibitor not tolerated) as first-line therapy for patients with significant proteinuria and renal impairment 7, 8
ACE inhibitors/ARBs reduce intraglomerular pressure and proteinuria independent of systemic BP reduction, and slow progression to end-stage renal disease in patients with CKD and proteinuria 9
Expect and tolerate up to 30% increase in serum creatinine after initiating ACE inhibitor/ARB therapy, which reflects hemodynamic changes from reduced intraglomerular pressure, not progressive kidney damage 10, 9

Restrict dietary sodium to <2 g/day to enhance antihypertensive medication effectiveness and reduce proteinuria, as recommended by the American Society of Nephrology 9