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Symptomatic Hypotension CKD Deprescribe — ESENeph MCQ

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ModerateHypertensionSymptomatic Hypotension CKD DeprescribeESENeph

A 60-year-old man with CKD G3b and hypertension is taking Ramipril 10 mg, Amlodipine 10 mg, and Dapagliflozin 10 mg. His BP is 115/68 mmHg with episodes of dizziness on standing. Postural drop is confirmed (20 mmHg systolic on standing). What adjustment is most appropriate?

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Correct answer: A — Reduce or stop the least evidence-based agent (Amlodipine) first while maintaining renoprotective agents (Ramipril, Dapagliflozin)

When symptomatic hypotension occurs in a CKD patient on multiple agents, the priority is to maintain the renoprotective medications (RASi and SGLT2i) while reducing the agent with the weakest CKD-specific evidence (in this case, Amlodipine). KDIGO 2024 emphasises the importance of maintaining RASi and SGLT2i even when BP is low, provided the patient is not symptomatic from those agents specifically. Dose reduction or withdrawal of the additional antihypertensive is preferred.

Reference: KDIGO 2024 – CKD Guideline; KDIGO 2021 – BP in CKD