Management of hypertension in chronic kidney disease

Hypertension is a major risk factor for cardiovascular (CV) disease and progression in chronic kidney disease (CKD). Blood pressure (BP) measurement should be standardised and supplemented by ambulatory and home BP monitoring. BP goals are generally <140/90 and <130/80 mmHg for those at higher risk of CV disease or CKD progression. Lifestyle modification includes restricting salt intake to <5 g/day. Most people with hypertension and CKD, especially those with a urine albumin:creatinine ratio ≥3 mg/mmol, should be treated with a renin-angiotensin system inhibitor to which, in selected individuals, a sodium-glucose co-transporter inhibitors type 2 and non-steroidal mineralocorticoid receptor antagonist may be added, followed by additional antihypertensives to achieve goal BP. Strategies to manage hyperkalaemia (eg low potassium dietary advice and oral potassium binders) should be employed to avoid stopping prognostically beneficial medications. A range of emerging therapeutics, including aldosterone synthase and endothelin antagonists, and renal denervation are briefly discussed.