Red Flags
- Hypertensive emergency with acute target organ damage (encephalopathy, ACS, acute pulmonary oedema, AKI) — IV antihypertensive in HDU[1]
- eGFR drop >30% within 4 weeks of starting or up-titrating ACEi/ARB — investigate for renal artery stenosis or volume depletion; do not automatically discontinue[1]
- Symptomatic orthostatic hypotension on multiple agents in elderly CKD — relax target; reduce dose; check medication review[1]
- Hyperkalaemia >5.5 mmol/L on RAS inhibitor — review potassium-sparing co-medications, dietary potassium, dose adjustment, potassium binders before withdrawal[1]
First-line treatment
Interventions
- Target systolic blood pressure <120 mm Hg by standardised office measurement[1]Adults with non-dialysis CKD without diabetic nephropathy should aim for SBP <120 by KDIGO standardised technique. Individualise in frail elderly, polypharmacy, severe orthostatic symptoms; SPRINT-style measurement is critical
- Sodium restriction <2 g/day[1]Cornerstone lifestyle intervention; potentiates RAS inhibitor effect and reduces albuminuria; renal dietitian if dietary patterns require restructuring
- Aerobic physical activity 4× weekly ≥150 min/week[1]Moderate-intensity aerobic activity reduces BP; resistance training adjunctive; tailor to functional status and dialysis schedule
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| ACE inhibitor or ARB (foundation therapy)[1] | Renin-angiotensin-aldosterone system inhibitor | Ramipril 2.5–10 mg PO daily; lisinopril 10–40 mg PO daily; losartan 50–100 mg PO daily; candesartan 8–32 mg PO daily; titrate to maximum tolerated | Children: weight-based; nephrology supervision | First-line in CKD with albuminuria (UACR ≥30 mg/g) and in diabetic CKD regardless of BP; do not combine ACEi with ARB; tolerate eGFR fall up to 30% from baseline; check K and creatinine 1–2 weeks after change |
| Dihydropyridine calcium channel blocker[1] | Calcium channel blocker | Amlodipine 5–10 mg PO daily; lercanidipine 10–20 mg PO daily | Amlodipine 0.1–0.6 mg/kg/day | Add-on to RAS inhibitor; safe across CKD stages; ankle oedema is dose-limiting |
| Thiazide-like diuretic[1] | Thiazide / thiazide-like diuretic | Indapamide 1.5 mg PO daily; chlortalidone 12.5–25 mg PO daily; hydrochlorothiazide 12.5–25 mg PO daily | — | Effective add-on even in eGFR 30–45; chlortalidone preferred over hydrochlorothiazide for outcomes; switch to loop diuretic when eGFR <30 with volume overload |
| Loop diuretic (furosemide or torsemide)[1] | Loop diuretic | Furosemide 20–80 mg PO daily or BD; torsemide 5–20 mg PO daily | Furosemide 1–2 mg/kg/dose | Volume control in CKD G4–G5 with fluid retention; torsemide has more reliable bioavailability |
| Spironolactone or eplerenone (resistant HTN)[1] | Mineralocorticoid receptor antagonist | Spironolactone 12.5–25 mg PO daily (avoid eGFR <30 routinely); eplerenone 25–50 mg PO daily | — | Add-on for resistant hypertension; monitor potassium closely; gynaecomastia with spironolactone (eplerenone alternative) |
ACE inhibitor or ARB (foundation therapy)[1]
Renin-angiotensin-aldosterone system inhibitor
- Adult
- Ramipril 2.5–10 mg PO daily; lisinopril 10–40 mg PO daily; losartan 50–100 mg PO daily; candesartan 8–32 mg PO daily; titrate to maximum tolerated
- Paediatric
- Children: weight-based; nephrology supervision
First-line in CKD with albuminuria (UACR ≥30 mg/g) and in diabetic CKD regardless of BP; do not combine ACEi with ARB; tolerate eGFR fall up to 30% from baseline; check K and creatinine 1–2 weeks after change
Dihydropyridine calcium channel blocker[1]
Calcium channel blocker
- Adult
- Amlodipine 5–10 mg PO daily; lercanidipine 10–20 mg PO daily
- Paediatric
- Amlodipine 0.1–0.6 mg/kg/day
Add-on to RAS inhibitor; safe across CKD stages; ankle oedema is dose-limiting
Thiazide-like diuretic[1]
Thiazide / thiazide-like diuretic
- Adult
- Indapamide 1.5 mg PO daily; chlortalidone 12.5–25 mg PO daily; hydrochlorothiazide 12.5–25 mg PO daily
- Paediatric
- —
Effective add-on even in eGFR 30–45; chlortalidone preferred over hydrochlorothiazide for outcomes; switch to loop diuretic when eGFR <30 with volume overload
Loop diuretic (furosemide or torsemide)[1]
Loop diuretic
- Adult
- Furosemide 20–80 mg PO daily or BD; torsemide 5–20 mg PO daily
- Paediatric
- Furosemide 1–2 mg/kg/dose
Volume control in CKD G4–G5 with fluid retention; torsemide has more reliable bioavailability
Spironolactone or eplerenone (resistant HTN)[1]
Mineralocorticoid receptor antagonist
- Adult
- Spironolactone 12.5–25 mg PO daily (avoid eGFR <30 routinely); eplerenone 25–50 mg PO daily
- Paediatric
- —
Add-on for resistant hypertension; monitor potassium closely; gynaecomastia with spironolactone (eplerenone alternative)
Safety-net
- Take ACE inhibitor / ARB even on days you feel fine — they protect the kidneys long-term, not just lower blood pressure short-term[1]
- If you develop dehydrating illness (vomiting, diarrhoea, fever) — temporarily hold ACE inhibitor / ARB, diuretic, and SGLT2 inhibitor for a day or two and seek review (sick-day rules)[1]
- New cough, swelling of lips/face, or persistent dizziness on standing — contact prescriber to review medication[1]
Referral criteria
- Resistant hypertension despite three antihypertensives including a diuretic at maximum tolerated dosesNephrology / hypertension clinic[1]
- Suspected secondary hypertension (renovascular, primary aldosteronism, phaeochromocytoma)Nephrology or endocrinology[1]
- eGFR fall >30% on RAS inhibitor or persistent hyperkalaemiaNephrology[1]
- Hypertensive emergencyEmergency department; HDU/ICU[1]
Clinical summary
Blood-pressure target, measurement, lifestyle, and pharmacotherapy for adults with non-dialysis CKD G1–G5; standardised office BP and ACEi/ARB foundation.