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Second-Line Antihypertensive CKD — ESENeph MCQ

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EasyHypertensionSecond-Line Antihypertensive CKDESENeph

A 55-year-old man with CKD G4 on Ramipril 10 mg has BP 132/82 despite the ACEi. According to KDIGO 2024, the target is systolic <120. What second-line antihypertensive should be added?

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Correct answer: A — A dihydropyridine calcium channel blocker (e.g. Amlodipine) or thiazide-like diuretic (Indapamide/Chlorthalidone) as second-line agents per NICE/KDIGO – choice depends on volume status, metabolic factors, and patient tolerance

For CKD patients already on ACEi/ARB who have not reached BP target, NICE NG136 step 2 adds either a CCB or thiazide-like diuretic. In CKD G4, thiazide-like diuretics become less effective (GFR-dependent sodium reabsorption) and loop diuretics may be preferred for fluid/BP control. CCBs (Amlodipine) maintain efficacy regardless of GFR. The choice between CCB and diuretic depends on clinical context: CCB for patients without oedema; diuretic for volume-overloaded patients. Dual RAS blockade (ACEi + ARB) is specifically contraindicated.

Reference: NICE NG136 2019; KDIGO 2024 – CKD