Hypertension Management in Chronic Kidney Disease: A Guide to the Latest Guidelines

Let's summarise all the major guidelines for managing hypertension in CKD patients

Introduction

Hypertension, defined as persistently elevated blood pressure (BP) above 130/80 mmHg, is a major risk factor for cardiovascular events like heart attacks, strokes, and heart failure. In individuals with chronic kidney disease (CKD), hypertension is even more prevalent and dangerous. It not only increases cardiovascular risk but also accelerates the decline in kidney function. Managing hypertension in CKD is therefore essential but presents unique challenges due to altered drug metabolism, fluid balance sensitivities, and the risks of further kidney damage with certain medications.

 

Key Guidelines:

 

KDIGO

The Kidney Disease: Improving Global Outcomes (KDIGO) organization provides the most comprehensive clinical practice guidelines for blood pressure management in CKD. Their 2021 update offers the following core recommendations:

 

Blood Pressure Targets:

KDIGO recommends a target blood pressure of <120/80 mmHg for adults with CKD, measured using standardized office blood pressure readings. (KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease: https://kdigo.org/guidelines/blood-pressure-in-ckd/)

 

Ambulatory Blood Pressure Monitoring (ABPM):

ABPM, which involves wearing a portable BP monitor for 24 hours, is recommended to confirm the diagnosis of hypertension and assess nocturnal BP patterns. This is especially valuable in CKD patients who may exhibit masked hypertension or white-coat hypertension.

 

Renin-Angiotensin System (RAS) Blockade:

Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are the first-line therapy for managing hypertension in CKD patients, especially those with proteinuria (protein in the urine). These medications not only lower blood pressure but also offer renoprotective effects (protecting the kidneys).

 

 

KDOQI Clinical Practice Guidelines for CKD

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) also provides guidelines for managing hypertension in CKD. Their recommendations are largely aligned with KDIGO:

 

Similar blood pressure targets (<120/80 mmHg):

See the KDOQI Clinical Practice Guideline for Diabetes and CKD: 2022 Update

 

Management of volume overload:

KDOQI emphasizes that in CKD patients with hypertension, controlling fluid balance is crucial. Diuretics are often needed in conjunction with other medications.

 

 

NICE Guidelines

The National Institute for Health and Care Excellence (NICE) provides guidelines specific to the UK. Their hypertension in adults guideline offers the following considerations in CKD:

 

Lifestyle modifications:

NICE strongly emphasizes healthy lifestyle changes as a cornerstone of hypertension management in all populations, including CKD patients. (https://www.nice.org.uk/guidance/ng136)

 

More conservative blood pressure targets in older adults:

NICE suggests a slightly less stringent blood pressure target of <140/90 mmHg for people aged over 80 years.

 

AHA/ACC and Other Relevant Guidelines

 The American Heart Association (AHA) and the American College of Cardiology (ACC) guidelines for hypertension management are also relevant, with some key considerations for CKD:

 

Choice of specific medication classes:

While ACEIs or ARBs are generally preferred, guidelines from AHA/ACC may provide more detailed recommendations within other drug classes such as calcium channel blockers and beta-blockers.

 

 

Practical Considerations

Choosing the right medications and promoting lifestyle changes are vital components of successful hypertension management in CKD.

 

Medication Choices

   * First-line: RAS inhibitors (ACE inhibitors or ARBs) are the foundation of therapy due to their blood-pressure-lowering effects and potential to slow CKD progression.

   * Diuretics: Often required, especially in later CKD stages. Loop diuretics are more effective when kidney function is reduced.

   * Calcium channel blockers: Can be a useful addition or alternative if RAS inhibitors are not tolerated.

   * Beta-blockers: Used with caution in CKD; selective agents may be preferred due to fewer metabolic side effects.

 

 

Lifestyle Modifications:

   * Sodium restriction: A critical aspect of blood pressure control in CKD. Aiming for <2 grams of sodium per day is recommended.

   * Weight management: If overweight or obese, weight loss can significantly improve blood pressure.

   * Exercise: Regular physical activity is beneficial for cardiovascular health and blood pressure.

   * Smoking cessation: Essential, as smoking worsens hypertension and accelerates kidney damage.

 

 

Controversies and Emerging Research

 * SGLT2 Inhibitors in CKD: Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a newer class of diabetes medications that also have blood-pressure-lowering and kidney-protective effects. Recent large trials like DAPA-CKD (https://www.nejm.org/doi/10.1056/NEJMoa2024816) and EMPA-KIDNEY  have demonstrated that SGLT2 inhibitors reduce the risk of CKD progression, cardiovascular events, and death, even in patients without diabetes. The role of SGLT2 inhibitors in CKD hypertension management is a rapidly evolving area.

 * Optimal Blood Pressure Targets in the Elderly or Frail: While strict blood pressure control is crucial in most CKD patients, extremely low targets might have disadvantages in older or frail individuals. There's ongoing debate about whether slightly higher blood pressure targets may be more appropriate for certain elderly CKD populations.

 

 

Conclusion

Hypertension management in chronic kidney disease is multifaceted and requires a tailored approach. Key takeaways from the latest guidelines include:

 * The importance of achieving a blood pressure target of <120/80 mmHg for most CKD patients.

 * Prioritizing RAS inhibitors (ACE inhibitors or ARBs) as first-line therapy, especially in those with proteinuria.

 * The value of lifestyle modifications, including sodium restriction, weight management, exercise, and smoking cessation.

 * Addressing volume overload through diuretic therapy when needed.

 * The potential role of SGLT2 inhibitors in offering broader benefits beyond blood pressure control in CKD.

Managing hypertension in CKD demands close collaboration between patients and their healthcare providers. Regular blood pressure monitoring and medication adjustments are essential to protect both heart and kidney health.

 

References

 * KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease: https://kdigo.org/guidelines/blood-pressure-in-ckd/

 * KDOQI Clinical Practice Guideline for Diabetes and CKD: 2022 Update ([invalid URL removed])

 * NICE Hypertension in Adults: diagnosis and management: https://www.nice.org.uk/guidance/ng136

 * Bakris, George L., et al. "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults." Journal of the American College of Cardiology 70.1 (2017).

 * DAPA-CKD Trial Investigators. "Dapagliflozin in Patients with Chronic Kidney Disease." New England Journal of Medicine 383.15 (2020): 1436-1446.

 * EMPA-KIDNEY Collaborative Group. "Empagliflozin in Patients with Established Chronic Kidney Disease and Cardiovascular Disease." New England Journal of Medicine. 2023 Jan 5;388(1):48-59.