Hypertension in chronic kidney disease

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.

References

1.KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease; KDIGO 2024 CKD Clinical Practice Guideline (BP harmonisation) (2021)