A European Renal Association (ERA) synopsis for nephrology practice of the 2023 European Society of Hypertension (ESH) Guidelines for the Management of Arterial Hypertension

Abstract

In June 2023, the European Society of Hypertension (ESH) presented and published the new 2023 ESH Guidelines for the Management of Arterial Hypertension, a document that was endorsed by the European Renal Association (ERA). Following the evolution of evidence in recent years, several novel recommendations relevant to the management of hypertension in patients with chronic kidney disease (CKD) appeared in these Guidelines. These include recommendations for target office blood pressure (BP) <130/80 mmHg in most and against target office BP <120/70 mmHg in all patients with CKD; recommendations for use of spironolactone or chlorthalidone for patients with resistant hypertension with estimated glomerular filtration rate (eGFR) higher or lower than 30 mL/min/1.73 m2, respectively; use of a sodium-glucose cotransporter 2 inhibitor for patients with CKD and estimated eGFR ≥20 mL/min/1.73 m2; use of finerenone for patients with CKD, type 2 diabetes mellitus, albuminuria, eGFR ≥25 mL/min/1.73 m2 and serum potassium <5.0 mmol/L; and revascularization in patients with atherosclerotic renovascular disease and secondary hypertension or high-risk phenotypes if stenosis ≥70% is present. The present report is a synopsis of sections of the ESH Guidelines that are relevant to the daily clinical practice of nephrologists, prepared by experts from ESH and ERA. The sections summarized are those referring to the role of CKD in hypertension staging and cardiovascular risk stratification, the evaluation of hypertension-mediated kidney damage and the overall management of hypertension in patients with CKD.

Keywords: albuminuria; blood pressure; chronic kidney disease; hypertension; hypertensive kidney disease.

Figure 1:

CV risk stratification according to grade and stage of hypertension (from [1], with permission). HMOD: hypertension-mediated organ damage, defined as increased large artery stiffness, non-hemodynamically significant atheromatous plaque (stenosis) on imaging, left ventricular hypertrophy, CKD G1–G2/A2 (i.e. albuminuria 30–300 mg/g with eGFR ≥60 mL/min/1.73 m²) or G3 (i.e. eGFR 30–59 mL/min/1.73 m²), ankle–brachial index <0.9 or advanced retinopathy.

Figure 2:

Treatment strategies in patients with hypertension and CKD (from [1], with permission).

Figure 3:

BP-lowering therapy in patients with hypertension and CKD. (A) Therapy for CKD G1–G3 (eGFR ≥30 mL/min/1.73 m²). (B) Therapy for CKD G4–G5 (eGFR <30 mL/min/1.73 m²) not on dialysis. (a) Transition from thiazide/thiazide-like (T/TL) diuretic to loop diuretic should be individualized in patients with eGFR <45 mL/min/1.73 m². (b) Cautious start with low dose. (c) Check for dose adjustment according to renal impairment for drugs with relevant renal excretion rate. (d) When SBP is ≥140 mmHg or DBP is ≥90 mmHg provided that: maximum recommended and tolerated doses of a three-drug combination comprising a RAS blocker (either an ACEi or an ARB), a CCB and a T/TL diuretic were used, adequate BP control has been confirmed by ABPM or by HBPM if ABPM is not feasible, various causes of pseudo-resistant hypertension (especially poor medication adherence) and secondary hypertension have been excluded. (e) Caution if eGFR <45 mL/min/1.73 m² or serum potassium >4.5 mmol/L. (f) Should be used at any step as guideline-directed medical therapy in respective indications or considered in several other conditions. (g) SGLT2is and finerenone should be used according to their approval for CKD treatment (from [1], with permission). T/TL: thiazide/thiazide-like.