hypertension in chronic kidney disease (CKD)

Last edited 09/2021 and last reviewed 09/2021

The cardiovascular complications of chronic renal failure are reduced by correction of hypertension

• hypertension
  • annual blood pressure measurement is indicated for all patients with CKD
  • life-style advice, including maintenance of normal body weight (body mass index 20-25 kg/m2), reduction of dietary sodium intake to < 100 mmol/day, regular aerobic physical exercise, and limitation of alcohol intake to no more than 3 units/day for men and 2 units/day for women
    • NICE suggest target blood pressure levels of:
      
      
      • in adults with CKD and an ACR under 70 mg/mmol, aim for a clinic systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a clinic diastolic blood pressure below 90 mmHg
      • in adults with CKD and an ACR of 70 mg/mmol or more, aim for a clinic systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a clinic diastolic blood pressure below 80 mmHg
      • in children and young people with CKD and an ACR of 70 mg/mol or more, aim for a clinic systolic blood pressure below the 50th percentile for height
      • pharmacotherapy for hypertension:
        • offer an angiotensin-receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor (titrated to the highest licensed dose that the person can tolerate) to adults, children and young people with CKD who have hypertension and an ACR over 30 mg/mmol (ACR category A3 or above)
          
          
      • many patients will need more than 2 drugs to achieve optimal control
        • ACEIs should be included in the regimen for all patients with:
          • diabetes and an ACR of 3 mg/mmol or more (ACR category A2 or A3)
          • hypertension and an ACR of 30 mg/mmol or more (ACR category A3)
          • an ACR of 70 mg/mmol or more (irrespective of hypertension or cardiovascular disease)
          • ARBs may be used as alternatives to ACEIs

      • ACR category	ACR (mg/mmol)
        A1	<3
        A2	3-30
        A3	>30

Notes:

• patients with refractory hypertension, defined as sustained BP > 150/90 despite combination therapy with drugs from 4 complementary classes, should be referred for specialist evaluation
• patients with accelerated or malignant phase hypertension should be referred to hospital immediately. Those in whom there is suspicion of underlying kidney disease should be referred to a nephrologist

Reference:

• (1) The Renal Association (May 2006).UK CKD Guidelines
• (2) NICE (August 2021). Chronic kidney disease: assessment and management