Hypertension management in patients with advanced chronic kidney disease with and without dialysis

PURPOSE OF REVIEW: Hypertension is a common comorbidity in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) on dialysis, contributing significantly to cardiovascular disease and increased mortality. Managing hypertension in this population is complex due to the frequent occurrence of resistant hypertension. This review highlights the recent updates in hypertension management for these patients, especially considering new guidelines and therapeutic options. RECENT FINDINGS: Recent literature emphasizes updated KDIGO guidelines, which have lowered blood pressure targets to decrease cardiovascular risks in patients with advanced CKD and ESKD. First-line therapies include diuretics, angiotensin converting enzyme inhibitors, and angiotensin II receptor blockers. New pharmacological treatments, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, endothelin receptor antagonists, RNA interference therapeutics, and aldosterone synthase inhibitors, offer promising options for resistant hypertension. Additionally, lifestyle modifications, including a low-salt diet and aerobic exercise, and volume control through ultrafiltration in dialysis patients, are crucial for blood pressure management. SUMMARY: The findings suggest that individualized treatment strategies, incorporating both pharmacologic and nonpharmacologic approaches, are essential for optimizing blood pressure control in patients with advanced CKD and ESKD. These strategies can improve cardiovascular outcomes and enhance patient quality of life, with important implications for clinical practice.