Hypertension in Advanced Chronic Kidney Disease: Saving the Kidneys or the Heart?

As one of the known modifiable risk factors for cardiovascular disease, hypertension control is an attractive strategy for mitigating the risk of chronic kidney disease progression and cardiovascular disease. However, trial data have not always been consistent in terms of the cardiovascular and kidney benefits of intensive blood pressure lowering in patients with advanced kidney dysfunction. Here, we provide an overview of the trial-grade evidence for intensive blood pressure lowering and the use of different antihypertensive agents to achieve blood pressure control, focusing on cardiorenal outcomes. The evolution of the field from the reliance on renin-angiotensin system inhibition as the first-line agent to control blood pressure to the approval of several newer therapies with proven kidney and cardiovascular benefits including sodium glucose co-transporter 2 inhibitors, nonsteroidal aldosterone antagonists, and glucagon-like peptide-1 agonists has advanced the care of patients with hypertension and CKD. However, evidence for these therapies remains more limited in those with advanced CKD. Further studies are needed in patients with advanced CKD who are at high risk for adverse side effects from antihypertensive therapy.