Initial Antihypertensive Medication for Elderly Patients with Stage 3 CKD

Rationale for ACE Inhibitor/ARB as First-Line

The American College of Cardiology and American Heart Association recommend ACE inhibitors or ARBs as preferred agents for patients with CKD (defined as stage 3 or higher), regardless of albuminuria presence 1, 2, 3
ACE inhibitors/ARBs are particularly important if albuminuria is present, and their use is recommended regardless of the patient's elderly status, with SPRINT data showing benefits in frail elderly patients ≥75 years with CKD 1, 2, 3

The American Geriatrics Society recommends checking renal function and serum potassium within 1-2 weeks of initiating ACE inhibitor therapy, then with each dose increase, and at least yearly thereafter 4
A 10-25% increase in serum creatinine may occur due to hemodynamic effects on intraglomerular pressure, which is generally acceptable and may be reversible, according to the American College of Cardiology 1, 2, 3
Creatinine increases >30% warrant investigation for other causes, including volume depletion, nephrotoxic agents, or renovascular disease, as stated by the American Heart Association 2, 3

The American College of Cardiology recommends a target BP of <130/80 mmHg in patients with CKD, based on SPRINT evidence showing cardiovascular and mortality benefits from intensive BP control in the CKD subgroup 1, 2, 3, 5
Patients with CKD can be assumed to have ≥10% 10-year ASCVD risk, placing them in the high-risk category requiring treatment initiation at BP ≥130/80 mmHg, according to the American Heart Association 1, 2, 3, 5

If an ACE inhibitor is not tolerated, the American College of Cardiology recommends switching to an ARB, as ARBs have been shown to be noninferior to ACE inhibitors in clinical trials 1, 2, 3
The combination of an ACE inhibitor with an ARB is contraindicated due to demonstrated harms, including increased hyperkalemia and hypotension without additional benefit, as stated by the American Heart Association 2, 3

If BP remains uncontrolled on maximally tolerated ACE inhibitor/ARB monotherapy, the American College of Cardiology recommends adding a thiazide-like diuretic or a dihydropyridine calcium channel blocker as second-line therapy 1, 2
Thiazide-like diuretics remain effective even with moderate renal impairment (GFR >30 mL/min), and monitoring of electrolytes is recommended within 1-2 weeks of initiation due to hypokalemia risk, according to the American Geriatrics Society 4

The American College of Cardiology recommends a blood pressure target of <130/80 mmHg for patients with CKD, as this population has substantially elevated cardiovascular risk and qualifies for intensive BP control 6

Calcium channel blockers combined with ACE inhibitors may slow CKD progression more effectively than ACE inhibitors combined with diuretics based on post hoc trial analysis 7

Treatment resistance in CKD is largely related to sodium and fluid retention with intravascular volume expansion, and most CKD patients require 3 or more antihypertensive agents to achieve BP control 8, 9

Regularly inquire about postural dizziness when treating elderly CKD patients with BP-lowering drugs, and always measure BP in both sitting and standing positions in elderly patients to assess for orthostatic hypotension 6