Optimizing blood pressure control in patients with chronic kidney disease.

The majority of patients with chronic kidney disease have hypertension, which is an independent risk factor for progression of kidney disease and cardiovascular disease. Therefore, hypertension should be stringently controlled to a blood pressure level of <130/80 mm Hg. Achieving this goal, which usually requires two or more antihypertensive agents, slows the progression of kidney disease and reduces the risk of cardiovascular disease. All antihypertensive treatments for patients with chronic kidney disease should include a renin-angiotensin-aldosterone system (RAAS) inhibitor (an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Initial therapy with fixed-dose RAAS inhibitor-based combinations should be considered, because this approach has been shown to bring significantly more patients to target blood pressure levels, compared with stepped-care treatment or sequential monotherapy. Fixed-dose combination therapy may also improve patient adherence to treatment by reducing the number of pills taken daily and the number of office visits for dosage adjustments. Recent clinical data suggest that the combination of a RAAS inhibitor and a dihydropyridine calcium channel blocker may provide more cardiovascular benefit than the generally recommended combination of a RAAS inhibitor and a diuretic in patients at high risk for cardiovascular events.