This article highlights evidence-based strategies for managing hypertension in chronic kidney disease, focusing on early intervention, guideline-directed therapies, and emerging treatments.

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Why This Matters

Hypertension and chronic kidney disease (CKD) frequently coexist, forming a vicious cycle that accelerates both kidney dysfunction and cardiovascular disease. Nearly 90% of patients with CKD are hypertensive, and failure to control blood pressure leads to faster progression to end-stage renal disease and a higher risk of cardiovascular morbidity.

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Evidence-Based Targets: KDIGO 2021 and the SPRINT Trial

1. The KDIGO 2021 guideline recommends a systolic blood pressure (SBP) target of less than 120 mmHg in CKD patients not on dialysis, provided this is measured using standardised techniques and is well-tolerated.
2. This recommendation stems from the SPRINT trial, which demonstrated a 25% reduction in major cardiovascular events and a 27% reduction in all-cause mortality in the intensive BP control group (<120 mmHg) versus standard control (<140 mmHg).
3. However, clinicians must remain vigilant about side effects such as hypotension and acute kidney injury, especially in older or frailer patients.

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What to Start With: Guideline-Based Therapy

First-line treatment for hypertension in CKD should follow guideline-based algorithms. ACE inhibitors or ARBs are recommended for all patients with albuminuria (UACR ≥30 mg/g), due to their renoprotective and antiproteinuric effects. In patients without albuminuria, calcium channel blockers or thiazide-like diuretics are appropriate.

The choice of diuretic should depend on kidney function: thiazides (e.g., chlorthalidone) are effective when eGFR >30 ml/min/1.73 m², while loop diuretics (e.g., furosemide, torsemide) are preferred in more advanced stages. SGLT2 inhibitors should be considered early for both their antihypertensive and cardiorenal protective effects.

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Resistant Hypertension: A Clinical Challenge

Resistant hypertension, defined as uncontrolled BP despite three or more antihypertensives (including a diuretic), is particularly common in CKD.

It often results from volume overload, suboptimal diuretic choice, excessive sodium intake, nonadherence, or secondary causes such as primary aldosteronism or renovascular disease.

Feehally emphasises that optimising diuretic therapy and reassessing volume status are foundational steps. For cases unresponsive to standard therapies, consider adding agents like finerenone or exploring polypill combinations.

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Case Scenario 1

A 60-year-old man with type 2 diabetes for 15 years and stage 3b CKD (eGFR 38 ml/min/1.73 m²), presented with persistently elevated BP in the range of 154–160/92–96 mmHg over the past 6 months. He was on telmisartan 80 mg, amlodipine 10 mg, and hydrochlorothiazide 25 mg.

Recent labs showed

• UACR: 540 mg/g
• HbA1c: 7.6%
• Serum K⁺: 4.7 mEq/L
• Na⁺: 139 mEq/L

Despite good medication adherence, he complained of mild ankle swelling and morning headaches.

What was done

• Switched HCTZ to furosemide 40mg
• Added empagliflozin 10 mg
• Reinforced dietary sodium restriction (<2 g/day)
• Introduced home BP monitoring
• Telmisartan reduced to 40mg

Outcome

At 8 weeks, BP improved to 128/78 mmHg, UACR dropped to 360 mg/g, and he reported better sleep. Creatinine remained stable, and potassium was 4.4 mEq/L.

Renal Denervation: Interventional Horizon.

Renal denervation (RDN) has re-emerged as an interventional option for truly resistant hypertension. Studies like SPYRAL HTN-ON MED and RADIANCE-HTN TRIO demonstrated sustained reductions in systolic BP in patients with poorly controlled hypertension despite optimised medical therapy. Though not yet routine, RDN is gaining momentum in select clinical settings, especially for patients who are nonadherent or unresponsive to anti-hypertensives.

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What’s New: Trials Shaping Hypertension in CKD

Recent clinical research is transforming how we approach hypertension in chronic kidney disease. The FLOW trial (2024) evaluated semaglutide in patients with type 2 diabetes and CKD, demonstrating not only a significant reduction in kidney disease progression and cardiovascular events but also a modest yet clinically relevant reduction in systolic blood pressure (~4–6 mmHg). This positions semaglutide as a valuable adjunct for patients with diabetes, CKD, and hypertension.

In parallel, renal denervation continues to gain traction, with trials like SPYRAL HTN-ON MED and RADIANCE-HTN TRIO reporting sustained blood pressure reductions in patients with resistant hypertension.

A Phase III trial is evaluating the combination of baxdrostat (a selective aldosterone synthase inhibitor) and dapagliflozin in hypertensive CKD patients, targeting dual inhibition of the RAAS and SGLT2 pathways for enhanced cardiorenal protection.

Diabetes, Hypertension, and Cardiovascular Risk: The Triple Burden.

In patients with CKD and diabetes, uncontrolled hypertension significantly raises the risk of adverse cardiovascular events. Management must be holistic, targeting blood pressure (<130 mmHg, ideally <120 mmHg), glycemic control (HbA1c ~7%), and lipid levels. SGLT2 inhibitors and GLP-1 receptor agonists are the cornerstone of therapy for their combined metabolic, cardiovascular, and renal benefits.

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Case Scenario 2: CKD Patient with Volume Overload

Patient is a 68-year-old retired schoolteacher with hypertensive nephrosclerosis and stage 4 CKD (eGFR 24 mL/min/1.73 m²). Her blood pressure readings hovered around 150/88 mmHg despite being on nifedipine 20mg and metoprolol 50mg. She reported morning headaches, mild fatigue, and recent weight gain (~2 kg).

Recent labs showed

• UACR: 210 mg/g
• K⁺: 4.3
• Na⁺: 138
• CXR: borderline cardiomegaly

She had visible oedema and shortness of breath on exertion earlier than usual.

Interventions

• Added furosemide 40 mg
• Advised salt and fluid restriction
• Added home BP monitoring

Outcome

At 4 weeks, home BP averaged 132/78 mmHg, weight decreased by 1.8 kg, and symptoms resolved. RAAS blockade can be considered on follow-up if renal function remains stable

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Your Pocket Guide to Hypertension in CKD

1. Use standardised BP measurement every time.

2. Aim for systolic BP <120 mmHg if tolerated.

3. Start ACEi or ARB in albuminuric CKD.

4. Use thiazide-like diuretics when eGFR >30; loop diuretics below that.

5. Introduce SGLT2 inhibitors early.

6. Reassess salt intake and volume status before adding more pills.

7. Consider finerenone, fixed-dose polypills, or RDN in resistant HTN.

8. Collaborate across nephrology, cardiology, and diabetology.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Anagha Auradkar is working as an assistant professor of Nephrology at  Dr B R Ambedkar Medical College, Bangalore.