Hypertension Treatment in Chronic Kidney Disease

Hypertension treatment in chronic kidney disease aims to slow loss of kidney function and reduce cardiovascular events. Target pressure is under 130/80 mmHg, and under 120 mmHg systolic if tolerated and measured with a consistent technique. In older or frail people, aim for under 140/90 mmHg. Salt restriction under 5 g daily raises the response to every drug class.

Albuminuria. When urine albumin to creatinine ratio is 3 mg/mmol (30 mg/g) or over, or when there is diabetes, an ACE inhibitor or angiotensin receptor blocker is first choice.

Volume. Most hypertension in chronic kidney disease is sodium and fluid driven, so a diuretic is often needed.

ACE inhibitor or angiotensin receptor blocker. Ramipril 2.5 mg orally once daily (1.25 mg if creatinine clearance is under 30 mL/min), increased every 2 to 4 weeks to 10 mg daily (maximum 5 mg daily if creatinine clearance is under 30 mL/min). Or losartan 50 mg once daily, maximum 100 mg. Never use both.

Calcium channel blocker. Amlodipine 5 mg orally once daily, maximum 10 mg. Needs no renal adjustment.

Diuretics. If eGFR is 30 mL/min/1.73 m2 or over, use indapamide 1.5 mg or chlorthalidone 12.5 to 25 mg once daily. If eGFR is under 30, use furosemide 40 mg orally once or twice daily, increased to 80 to 160 mg twice daily if needed. Chlorthalidone 12.5 to 25 mg lowers pressure even at stage 4 but needs close electrolyte checks.

Mineralocorticoid antagonists. Spironolactone 12.5 to 25 mg once daily as a fourth drug, only when potassium is under 4.8 mmol/L and eGFR is over 30.

Kidney-protective add-ons. Dapagliflozin 10 mg or empagliflozin 10 mg orally once daily when eGFR is 20 to 25 mL/min/1.73 m2 or over. In type 2 diabetes with albuminuria and potassium of 4.8 mmol/L or under, finerenone 10 mg once daily if eGFR is 25 to 59, or 20 mg if eGFR is 60 or over.

Special groups. In dialysis, ACE inhibitors such as lisinopril and enalapril are removed, so dose after dialysis. In pregnancy, use labetalol or nifedipine. In older adults start at half dose.

Monitoring. Check creatinine and potassium 1 to 2 weeks after starting or changing an ACE inhibitor or angiotensin receptor blocker. Accept a creatinine rise of up to 30%. Check potassium again at 4 weeks.

Hyperkalaemia. If potassium is 5.5 to 5.9 mmol/L, reduce the dose, review diet and drugs, and consider a potassium binder. If 6.0 mmol/L or over, stop and treat.

Sick day rule. Withhold ACE inhibitors, angiotensin receptor blockers, diuretics, SGLT2 inhibitors and NSAIDs during vomiting, diarrhoea or poor intake.

Stopping. Stop an ACE inhibitor or angiotensin receptor blocker for angioedema, potassium of 6.0 mmol/L or over, or a creatinine rise over 30% not explained by volume depletion. Do not stop for eGFR decline under 30% alone.

Common errors. Combining an ACE inhibitor with an angiotensin receptor blocker, NSAID use, stopping renin blockade at the first creatinine rise, and omitting a diuretic when oedema is present.

Referral and escalation. Refer to nephrology for eGFR under 30 mL/min/1.73 m2, rapid decline, albumin to creatinine ratio over 70 mg/mmol (700 mg/g), or pressure not at target on four drugs.