Chronic kidney disease (CKD) is a major non-communicable disease with rising clinical and public health relevance in India and globally. It is characterized by persistent structural or functional kidney abnormality and is associated with progressive renal impairment, cardiovascular disease, hospitalization, and premature mortality. Community and hospital-based Indian studies have shown that hypertension and diabetes are among the dominant risk factors identified in patients with CKD [1,2]. As CKD advances, the need for sustained monitoring of blood pressure, renal function, proteinuria, electrolytes, and medication safety becomes increasingly important.

Hypertension and CKD have a bidirectional relationship. Long-standing hypertension contributes to nephrosclerosis, glomerular injury, and progressive decline in glomerular filtration rate, while reduced kidney function promotes sodium retention, volume expansion, endothelial dysfunction, arterial stiffness, sympathetic activation, and renin-angiotensin-aldosterone system stimulation [5-7]. This complex pathophysiology explains why blood pressure control in CKD is often more difficult than in uncomplicated essential hypertension. Patients frequently require two or more antihypertensive drugs, and treatment decisions must balance blood pressure reduction, renal protection, potassium status, volume control, and tolerability [5,8].

Guidelines emphasize accurate blood pressure measurement, lifestyle modification, sodium restriction, individualized risk assessment, and appropriate pharmacological therapy in CKD. Renin-angiotensin system blockers are generally preferred when albuminuria or proteinuric kidney disease is present, while calcium channel blockers, diuretics, beta-blockers, and other agents are added according to volume status, CKD stage, comorbid cardiovascular disease, and residual blood pressure elevation [3,4,11]. However, real-world prescribing differs between institutions because of patient profile, affordability, drug availability, physician preference, electrolyte abnormalities, and concerns regarding worsening renal function or hyperkalemia.

Several studies have reported that hypertension awareness and treatment have improved, but adequate blood pressure control remains difficult among CKD patients [8,9]. Large cohort data have also shown that antihypertensive regimens and drug combinations vary by CKD stage, comorbidity burden, and baseline blood pressure [9,10]. In India, local hospital-based data remain useful because treatment patterns are shaped by regional patient characteristics, late presentation, diabetes burden, access to nephrology care, and routine prescribing practices. Periodic assessment of drug utilization and blood pressure control can guide rational treatment review in tertiary care settings.

The present study was conducted with the objectives of assessing the pattern of antihypertensive drug use among patients with CKD and hypertension, estimating the proportion of patients achieving blood pressure control, and describing blood pressure control according to CKD stage, diabetes status, and commonly used antihypertensive combinations.

Study design and setting: This hospital-based observational study was conducted in the Department of General Medicine/Nephrology services at Chalmeda Ananda Rao Institute of Medical Sciences, Karimnagar, Telangana, India. The institute is a tertiary care teaching hospital that provides outpatient, inpatient, emergency, intensive care, laboratory, imaging, and specialty services to patients from Karimnagar and surrounding districts. Patients with chronic medical disorders, including CKD, diabetes mellitus, hypertension, cardiovascular disease, and related complications, are regularly evaluated and managed in the hospital. Study period and sample size: The study was carried out over a six-month period from October 2025 to March 2026. A total of 80 adult patients with CKD and hypertension who fulfilled the eligibility criteria during the study period were included. The sample size was based on feasible enrolment of eligible patients attending the hospital during the defined period. Study population: Adult patients aged 18 years and above with diagnosed CKD and hypertension were considered eligible. CKD was defined based on documented clinical diagnosis, reduced estimated glomerular filtration rate, or persistent kidney disease-related abnormality recorded in the medical file. Hypertension was defined by previous diagnosis, current use of antihypertensive medication, or elevated blood pressure recorded during clinical assessment. Patients with acute kidney injury, pregnancy, incomplete treatment records, and those unwilling to provide consent were excluded. Data collection: After obtaining informed consent, demographic and clinical details were recorded using a structured data collection form. Age, sex, duration of hypertension, presence of diabetes mellitus, CKD stage, systolic blood pressure, diastolic blood pressure, prescribed antihypertensive drug classes, number of antihypertensive drugs, and common drug combinations were documented. CKD stage was classified as stage III, stage IV, or stage V according to the available renal function records. Blood pressure was measured during clinical evaluation using standard hospital practice. Controlled blood pressure was operationally defined as systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg, consistent with the pragmatic threshold used for descriptive analysis in this study. Statistical analysis: Data were entered into Microsoft Excel and analyzed using descriptive statistics. Continuous variables were summarized as mean and standard deviation. Categorical variables were expressed as frequencies and percentages. Antihypertensive drug class use was calculated separately for each class because patients received more than one drug. Blood pressure control was described overall and according to selected clinical and treatment variables. No inferential statistical testing was applied because the study was designed as a descriptive observational analysis. Ethical considerations: The study was conducted after approval from the Institutional Ethics Committee of Chalmeda Ananda Rao Institute of Medical Sciences, Karimnagar, Telangana, India. Written informed consent was obtained from all participants before enrolment. Patient confidentiality was maintained throughout the study, and data were used only for academic and research purpose.

A total of 80 patients with chronic kidney disease and hypertension were included in the study. The mean age of the study population was 56.8 ± 12.4 years. Most patients were above 50 years of age, with the highest proportion in the 51-60 years age group. Males constituted 60.0% of the study population. Diabetes mellitus was present in 52.5% of patients. Stage IV CKD was the most common stage, followed by stage III CKD. The baseline demographic and clinical characteristics are shown in Table 1.

Table 1. Baseline demographic and clinical characteristics of the study population

The mean systolic blood pressure was 148.6 ± 18.7 mmHg, and the mean diastolic blood pressure was 86.4 ± 10.8 mmHg. Overall, blood pressure was controlled in 35 patients, while 45 patients had uncontrolled blood pressure. Systolic blood pressure was elevated in a higher proportion of patients than diastolic blood pressure. The blood pressure profile of the study population is presented in Table 2.

Table 2. Blood pressure profile among patients with chronic kidney disease

Calcium channel blockers were the most commonly prescribed antihypertensive drugs, followed by diuretics, ACE inhibitors/ARBs, and beta-blockers. Alpha-blockers, centrally acting drugs, and mineralocorticoid receptor antagonists were used less frequently. Since several patients received more than one antihypertensive drug, drug class percentages exceeded 100%. Monotherapy was used in only 17.5% of patients, while most patients received two or more drugs. The pattern of antihypertensive drug use is summarized in Table 3.

Table 3. Pattern of antihypertensive drug use

Note: Drug class percentages exceed 100% because several patients received more than one antihypertensive drug.

The most frequent regimen was triple therapy with ACE inhibitor/ARB, calcium channel blocker, and diuretic, followed by calcium channel blocker with diuretic and ACE inhibitor/ARB with calcium channel blocker. Blood pressure control was better among patients with stage III CKD compared with those with stage V CKD. Patients with diabetes mellitus showed a higher proportion of uncontrolled blood pressure than those without diabetes mellitus. Common drug combinations and blood pressure control according to selected variables are shown in Table 4.

Table 4. Common drug combinations and blood pressure control according to clinical variables

Overall, multidrug therapy was frequently required for blood pressure management among CKD patients. Calcium channel blockers, diuretics, and ACE inhibitors/ARBs formed the major prescribing pattern. Despite treatment, more than half of the patients had uncontrolled blood pressure, especially those with advanced CKD and diabetes mellitus.

The present hospital-based observational study evaluated antihypertensive drug use and blood pressure control among 80 patients with CKD and hypertension. The study population was predominantly middle-aged to elderly, and males formed a larger proportion of patients. Diabetes mellitus was documented in more than half of the participants, reflecting the common overlap between diabetes, hypertension, and CKD in Indian clinical settings. Indian epidemiological studies and the ICKD cohort have similarly emphasized the strong clustering of hypertension and diabetes among patients with CKD [1,2].

Blood pressure control was achieved in 43.8% of patients, indicating that more than half remained uncontrolled despite ongoing pharmacological therapy. This finding is clinically relevant because CKD-associated hypertension is often resistant to simple treatment strategies due to volume overload, vascular stiffness, activation of the renin-angiotensin-aldosterone system, and sympathetic overactivity [5-7]. Previous studies have also reported suboptimal blood pressure control among CKD patients despite high awareness and treatment rates [8,9]. In the CRIC study, blood pressure control varied across patient groups and was influenced by comorbidity burden, CKD severity, and number of medications [9].

Calcium channel blockers were the most frequently prescribed drug class in this study, followed by diuretics, ACE inhibitors/ARBs, and beta-blockers. This pattern reflects a practical approach in routine care, particularly when patients have advanced CKD, edema, volume-dependent hypertension, or concerns related to hyperkalemia. Guidelines support renin-angiotensin system blockade, especially in patients with albuminuria, but also recognize the need for complementary drug classes such as diuretics and calcium channel blockers for achieving blood pressure targets [3,4,11]. In contrast, Magvanjav et al. reported ACE inhibitor/ARB use as the most common class in a large electronic health record-based CKD cohort, highlighting differences between study populations and prescribing environments [10].

Multidrug therapy was common, with 82.5% of patients receiving two or more antihypertensive agents. This is consistent with the known difficulty of treating hypertension in CKD and with previous reports showing an increasing number of antihypertensive drugs as kidney disease progresses [10,12]. The most frequent regimen in the present study was ACE inhibitor/ARB with calcium channel blocker and diuretic, a rational combination that targets renin-angiotensin activation, vascular resistance, and volume excess. However, the persistence of uncontrolled blood pressure in many patients suggests the need for treatment intensification, adherence assessment, dietary sodium review, and follow-up blood pressure monitoring.

Blood pressure control declined with advancing CKD stage. Patients with stage V CKD had the highest proportion of uncontrolled blood pressure, which is expected because advanced renal dysfunction intensifies salt and water retention, arterial stiffness, and medication complexity [5,7]. Diabetes mellitus was also associated with poorer control, supporting the concept that diabetic CKD represents a high-risk subgroup requiring closer therapeutic monitoring. Overall, the findings reinforce the importance of individualized treatment, rational combination therapy, periodic drug review, and integrated physician-nephrologist care in CKD-associated hypertension [13,14].

Limitations

This study had a single-centre hospital-based design with a limited sample size. Blood pressure was assessed using clinic readings rather than ambulatory or home monitoring. Drug adherence, dietary sodium intake, albuminuria status, serum potassium trends, and long-term renal or cardiovascular outcomes were not evaluated. Therefore, the findings describe prescribing patterns and blood pressure status but do not establish causal associations.

In this hospital-based observational study, blood pressure control was achieved in less than half of patients with chronic kidney disease and hypertension. Calcium channel blockers, diuretics, and ACE inhibitors/ARBs were the leading antihypertensive drug classes, and most patients required multidrug therapy. Uncontrolled blood pressure was more frequent among patients with advanced CKD and diabetes mellitus, indicating the need for close clinical review in these groups. The findings highlight the complexity of hypertension management in CKD and support structured blood pressure monitoring, individualized drug combinations, adherence assessment, and timely treatment optimization to reduce renal and cardiovascular risk in routine tertiary care practice through coordinated follow-up, medication review, and patient-centred clinical decision-making.

Reddy SR, Acharya VN, et al. Epidemiology and risk factors of chronic kidney disease in India: results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol. 2013;14:114. doi:10.1186/1471-2369-14-114.

2. Kumar V, Yadav AK, Sethi J, Ghosh A, Sahay M, Prasad N, et al. The Indian Chronic Kidney Disease (ICKD) study: baseline characteristics. Clin Kidney J. 2022;15(1):60-69. doi:10.1093/ckj/sfab149.
3. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314.
4. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021;99(3S):S1-S87.
5. Pugh D, Gallacher PJ, Dhaun N. Management of hypertension in chronic kidney disease. Drugs. 2019;79(4):365-379. doi:10.1007/s40265-019-1064-1.
6. Hamrahian SM, Falkner B. Hypertension in chronic kidney disease. Adv Exp Med Biol. 2017;956:307-325. doi:10.1007/5584_2016_84.
7. Horowitz B, Miskulin D, Zager P. Epidemiology of hypertension in CKD. Adv Chronic Kidney Dis. 2015;22(2):88-95. doi:10.1053/j.ackd.2014.09.004.
8. Sarafidis PA, Li S, Chen SC, Collins AJ, Brown WW, Klag MJ, Bakris GL. Hypertension awareness, treatment, and control in chronic kidney disease. Am J Med. 2008;121(4):332-340. doi:10.1016/j.amjmed.2007.11.025.
9. Muntner P, Anderson A, Charleston J, Chen Z, Ford V, Makos G, et al. Hypertension awareness, treatment, and control in adults with CKD: results from the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis. 2010;55(3):441-451. doi:10.1053/j.ajkd.2009.09.014.
10. Magvanjav O, Cooper-DeHoff RM, McDonough CW, Gong Y, Segal MS, Johnson JA, et al. Antihypertensive therapy prescribing patterns and correlates of blood pressure control among hypertensive patients with chronic kidney disease. J Clin Hypertens (Greenwich). 2019;21(1):91-101. doi:10.1111/jch.13429.
11. Sinha AD, Agarwal R. Clinical pharmacology of antihypertensive therapy for the treatment of hypertension in CKD. Clin J Am Soc Nephrol. 2019;14(5):757-764. doi:10.2215/CJN.04330418.
12. Carey RM, Calhoun DA, Bakris GL, Brook RD, Daugherty SL, Dennison-Himmelfarb CR, et al. Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension. 2018;72(5):e53-e90. doi:10.1161/HYP.0000000000000084.
13. Cheung AK, Rahman M, Reboussin DM, Craven TE, Greene T, Kimmel PL, et al. Effects of intensive BP control in CKD. J Am Soc Nephrol. 2017;28(9):2812-2823. doi:10.1681/ASN.2017020148.
14. Wright JT Jr, Bakris G, Greene T, Agodoa LY, Appel LJ, Charleston J, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288(19):2421-2431. doi:10.1001/jama.288.19.2421.