Essential Hypertension with Chronic Kidney Disease: What to Do When RAAS Inhibitor Therapy Does Not Reach SBP <130 mm Hg

Clinical Scenario

This protocol applies to adults with essential hypertension and concurrent chronic kidney disease, defined by an eGFR below 60 mL/min/1.73 m² or a urine albumin-to-creatinine ratio of 30 mg/g or higher. Reaching an SBP below 130 mm Hg in this population reduces all-cause mortality.

Prior Treatment — Target Not Achieved

First-line therapy with a renin-angiotensin-aldosterone system inhibitor — either an ACE inhibitor or an angiotensin receptor blocker (not both simultaneously) — did not achieve the SBP goal of <130 mm Hg. This protocol defines the structured next step.

Next-Line Approach (Partial Overview)

The protocol specifies adding further antihypertensive agents from additional drug classes to the existing RAAS-blocking regimen, with guidance on how the current RAAS inhibitor should be managed as kidney function declines. Complete agent selection, titration rules, and eGFR-based decision points are in the full regimen.

Full sequencing, class selection, and eGFR thresholds available in the complete protocol below.

Treatment Target

SBP <130 mm Hg.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1161/CIR.0000000000001356

For adults with hypertension and CKD as identified by eGFR <60 mL/min/1.73 m² or albuminuria ≥30 mg albumin/g creatinine, treatment should target an SBP goal of <130 mm Hg to decrease all-cause mortality.

ACEi or ARB can be continued in people with eGFR <30 mL/min/1.73 m² as an RCT found that discontinuation was not associated with a significant difference in long-term decrease in eGFR.

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