Special Concideration of Hypertension: Chronic Kidney Disease

In people with chronic kidney disease (CKD), as defined by either reduced excretory function with an estimated GFR below 60 ml/min per 1.73 m2 (corresponding approximately to a creatinine of >1.5 mg/dL in men or >1.3 mg/dL in women),20 or (2) the presence of albuminuria (>300 mg/day or 200 mg albumin/g creatinine), therapeutic goals are to slow deterioration of renal function and prevent CVD. Hypertension appears in the majority of these patients, and they should receive aggressive BP management, often with three or more drugs to reach target BP values of <130/80 mmHg. ACEIs and ARBs have demonstrated favorable effects on the progression of diabetic and nondiabetic renal disease. A limited rise in serum creatinine of as much as 35 percent above baseline with ACEIs or ARBs is acceptable and is not a reason to withhold treatment unless hyperkalemia develops.With advanced renal disease (estimated GFR <30 ml/min 1.73 m2, corresponding to a serum creatinine of 2.5–3 mg/dL), increasing doses of loop diuretics are usually needed in combination with other drug classes.