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Thiazide-like diuretics in hypertension with CKD stage 4, a new approach?
A randomized controlled trial (CLICK trial) showed that adding chlorthalidone to traditional anti-hypertensive medications with stage 4 CKD reduced SBP by 11 mm Hg.
Hypertension (HTN) is common in chronic kidney disease (CKD) and can worsen its progression.
While the optimal blood pressure (BP) target for CKD patients remains unclear, a systolic BP (SBP) of ≤130 mmHg is generally acceptable. However, the 2021 Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend more intensive treatment for an SBP of <120 mmHg.
ACE inhibitors (ACEi) or angiotensin receptor blockers (ARBs) are the cornerstone of CKD hypertension management.
Yet, there is less consensus on the second-line medications. Calcium channel blockers (CCBs), like amlodipine, are commonly used as a second-line treatment.
But what about diuretics?
They are often underutilized in CKD patients with hypertension.
Thiazide-like diuretics, such as chlorthalidone, should be considered when considering diuretics for these patients.
Traditionally, it’s believed that thiazide diuretics lose effectiveness at lower GFR levels, and guidelines recommend switching to loop diuretics when GFR drops below 30.
However, a randomized controlled trial (CLICK trial) showed that adding chlorthalidone to traditional antihypertensives reduced SBP by 11 mmHg in patients with stage 4 CKD.
Should we start treating hypertension with CKD stage 4 (eGFR 15-29) with chlorthalidone?
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