Hypertension in chronic kidney disease-treatment standard 2023
Hypertension is prevalent among patients with chronic kidney disease (CKD) and is often inadequately controlled. Accurate blood pressure (BP) measurement is a critical first step in diagnosing and managing hypertension. While dietary sodium restriction is frequently overlooked, it can significantly enhance BP control, particularly in patients receiving treatment to block the renin-angiotensin system. In cases of very high albuminuria, international guidelines consistently recommend using angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) as the first-line antihypertensive agents. Long-acting dihydropyridine calcium channel blockers and diuretics are suitable options for second- and third-line treatments. For patients with treatment-resistant hypertension, guidelines suggest adding spironolactone to the existing antihypertensive regimen. However, the risk of hyperkalemia limits the widespread use of spironolactone in those with moderate to advanced CKD.
Evidence from the CLICK (Chlorthalidone in Chronic Kidney Disease) trial indicates that the thiazide-like diuretic chlorthalidone is effective and provides an alternative therapeutic option for patients with stage 4 CKD and uncontrolled hypertension, including those with treatment-resistant hypertension. Chlorthalidone can also reduce the risk of hyperkalemia, allowing for the safe use of spironolactone; however, this combination necessitates careful monitoring of BP and kidney function to prevent adverse effects.
Emerging treatments, such as the non-steroidal mineralocorticoid receptor antagonist ocedurenone, the dual endothelin receptor antagonist aprocitentan, and the aldosterone synthase inhibitor baxdrostat, present new targets and strategies for better BP control. Larger, long-term clinical trials are needed to establish the safety and efficacy of these novel therapies. In this article, we review current treatment standards and discuss recent advancements in the pathophysiology, diagnosis, outcome prediction, and management of hypertension in CKD patients.