Resistant hypertension in CKD — ESENeph MCQ

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HardHypertension and Renovascular DiseaseResistant hypertension in CKDESENeph

A patient has confirmed resistant hypertension on an ACE inhibitor, calcium-channel blocker and thiazide-like diuretic. eGFR is 42 mL/min/1.73 m² and potassium is 4.6 mmol/L. Which is the most appropriate fourth-line approach?

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Correct answer: A — An alpha- or beta-blocker with specialist review

NICE reserves low-dose spironolactone at step 4 for potassium 4.5 mmol/L or lower, with caution as eGFR falls. With potassium above this threshold, an alpha- or beta-blocker is considered and specialist advice is appropriate. Adding an MRA at 4.6 mmol/L as an automatic answer understates hyperkalaemia risk. The competing options do not fit the renal phenotype, temporal relationship, treatment threshold or safety constraint described. Management still requires confirmation of current medicines, renal trajectory and relevant contraindications, followed by timely biochemical and clinical reassessment. Escalate urgently if life-threatening electrolyte disturbance, respiratory compromise, shock, neurological deterioration or a dialysis indication develops.

Reference: NICE NG136: Hypertension in adults. https://www.nice.org.uk/guidance/ng136/chapter/recommendations