Management Strategies for Hypertensive Nephropathy in CKD Patients
Overview
As a clinical pharmacist, effective BP management in CKD is essential to slow disease progression and reduce complications. Following ACC/AHA and KDIGO guidelines, you can set BP targets and select optimal medications. Below are key strategies for managing BP and addressing CKD risk factors...
Management steps
Lifestyle & dietary adjustments
Encourage patients to reduce salt intake (at least 4 weeks to see effects), follow the DASH diet, and exercise 150 minutes per week. Advise quitting smoking for slower GFR decline and better overall health. Control diabetes and other risk factors to further protect kidney function.
Select antihypertensive agents
Set BP targets. Target BP < 130/80 mm Hg for CKD patients based on ACC/AHA and KDIGO guidelines, especially if urine albumin is ≥ 30 mg/24 hours.
- Start an ACEI or ARB for patients with albuminuria > 300 mg/g or mg/day to lower BP and protect the kidneys.
- For those who can’t tolerate ACEIs/ARBs, consider non-dihydropyridine CCBs (like verapamil or diltiazem) as a second-line option for BP control and antiproteinuric benefits.
- Add other BP medications as needed, but pair with ACEIs/ARBs unless contraindicated. No trials suggest a clear advantage between ACEIs and ARBs, so treat them as a class effect.
Add SGLT2 inhibitors
Consider SGLT2 inhibitors for added benefit. For CKD patients with GFR between 25 and 75 (with or without T2DM), consider dapagliflozin 10 mg daily to lower the risk of death and reduce the need for dialysis or transplant. This therapy shows renal and cardiovascular protection when taken for about 2.4 years.
Other recommendations
Treat metabolic acidosis if bicarbonate < 20 mEq/L. Reinforce the importance of regular follow-up and monitoring of kidney function when starting or adjusting therapy. Discuss how controlling BP and adopting lifestyle changes can prevent CKD complications and improve outcomes.
References
- James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.
- Staplin N, Haynes R, Herrington WG, et al. Smoking and Adverse Outcomes in Patients With CKD: The Study of Heart and Renal Protection (SHARP). Am J Kidney Dis. 2016;68(3):371-380.
- Whelton PK, Carey RM, Aronow WS, 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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e13-e115.
- Bakris GL, Sarafidis PA, Weir MR, et al. Renal outcomes with different fixed-dose combination therapies in patients with hypertension at high risk for cardiovascular events (ACCOMPLISH): a prespecified secondary analysis of a randomised controlled trial. Lancet. 2010;375(9721):1173-1181.
- Inker LA, Astor BC, Fox CH, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. Am J Kidney Dis. 2014;63(5):713-735.
