Treatment of Hypertension in Patients with CKD Stages 1-4

Key point

Control of hypertension is the single most effective intervention for slowing the rate of decline in renal function of patients with CKD.

Target

Blood pressure should be lowered to <130/80 mmHg in all patients with CKD

o There is some evidence that a lower target of <125/75 mmHg may provide additional benefit in patients with >1g/day of proteinuria (urine protein:creatinine ratio >1mg/mg or >100mg/mmol)

Therapeutic agents

Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs) afford renal protection that is in addition to their antihypertensive effects. ACEI or ARB should therefore be regarded as first-line antihypertensive therapy for all patients with CKD (see safety guidance).

The level of proteinuria is a strong predictor of long-term renal prognosis. ACEI or ARB dose should therefore be increased until proteinuria has been decreased to <1g/day (urine protein:creatinine ratio <1mg/mg or <100mg/mmol).

If the blood pressure goal is not achieved with maximum dose ACEI or ARB treatment, additional antihypertensive treatment should be added to lower blood pressure to target. A thiazide or loop diuretic is often very effective if used in combination with an ACEI or ARB, as the initial additional agent.

If the proteinuria goal is not achieved with maximum dose ACEI or ARB, combination ACEI and ARB therapy should be considered. This should however be done only under the supervision of the Renal Medicine Clinic.