Season-adaptive blood pressure management in older adults with CKD: a practical review

Blood pressure management in chronic kidney disease (CKD) is often approached as a relatively stable, year-round therapeutic task. In older adults, however, this assumption may be misleading. During warm weather, seasonal declines in blood pressure may interact with frailty, impaired thirst response, orthostatic vulnerability, reduced renal autoregulatory reserve, reduced intake, and fixed-dose antihypertensive prescribing, thereby increasing the risk of symptomatic hypotension, falls, volume depletion, hypoperfusion-related acute kidney injury (AKI), and interruption of organ-protective therapy. Despite this vulnerability, antihypertensive therapy may remain insufficiently reassessed across seasons, with limited attention to dynamic changes in home blood pressure, body weight, symptoms, and kidney function. In this practical review, we examine the clinical rationale for season-adaptive blood pressure management in older adults with CKD. We discuss why this population is particularly susceptible to seasonal over-lowering of blood pressure and kidney hypoperfusion, how this vulnerability may differ across CKD phenotypes, and why fixed prescribing may become maladaptive in routine care. We summarize pragmatic indicators of emerging risk, including home blood pressure trends, diurnal blood pressure patterns when relevant, body weight assessment at each clinic visit, body weight trajectory over time, orthostatic symptoms and blood pressure changes, and serial serum creatinine and estimated glomerular filtration rate measurements. We also address the supportive but limited role of urinary markers such as urinary albumin-creatinine ratio and spot urinary sodium indices. A season-adaptive approach may help reduce avoidable hypotension and hypoperfusion-related AKI while supporting the safer and more sustainable use of organ-protective therapy in older adults with CKD.