Antihypertensive Pharmacotherapy in Chronic Kidney Disease: Integrating eGFR-Based Cutoffs, Mechanistic Insights, and Emerging Therapeutic Pathways

Optimal hypertension management requires not only stringent blood pressure control but also concomitant management of related cardiovascular, metabolic, and kidney comorbidities. Emerging evidence demonstrates that contemporary therapies improve albuminuria, estimated glomerular filtration rate trajectory, kidney outcomes, and cardiovascular outcomes, although the relative contributions of sustained blood pressure reduction and other biologic effects cannot always be separated. This review examines the impact of current and emerging treatment strategies across three core domains: blood pressure control, kidney function trajectory, and albuminuria reduction. Emphasis is placed on kidney function-based treatment selection, safety considerations including advanced disease, the role of targeted therapy in dysregulated aldosterone states, and evolving options for resistant hypertension. A risk- and clinical-characteristic-guided approach that integrates kidney stage, degree of albuminuria, and overall cardiovascular risk is proposed to move beyond uniform drug escalation toward personalized care. Early risk stratification, thoughtful sequencing, and structured monitoring are essential to translate therapeutic advances into sustained kidney and cardiovascular benefit.