Hypertension in chronic kidney disease: where do international guidelines converge and diverge?

In recent years, major scientific societies have updated their hypertension guidelines, each incorporating specific recommendations for patients with chronic kidney disease (CKD). Across societies, there is strong consensus on standardized office and out-of-office blood pressure (BP) measurement, as well as systematic assessment of estimated glomerular filtration rate and albuminuria, with confirmation of abnormalities and regular monitoring. Moderate-to-severe CKD is universally recognized as a major determinant of cardiovascular (CV) risk and is frequently considered equivalent to established CV disease, thereby supporting earlier and more intensive BP treatment. Although BP thresholds for treatment initiation and on-treatment BP targets remain debated, there is broad agreement on the preferential use of dual-agent combination therapy, including surely renin-angiotensin system inhibitors in patients with albuminuric CKD-together with calcium-channel blockers or diuretics, with diuretic selection largely guided by renal function. Moreover, contemporary guidelines increasingly emphasize disease-modifying strategies, including sodium-glucose cotransporter 2 inhibitors and nonsteroidal mineralocorticoid receptor antagonists in selected patients, to improve cardio-renal outcomes. Despite differences in definitions, targets, and treatment algorithms, all guidelines converge on a patient-centered approach prioritizing cardio-renal protection, adherence, and individualized care. With this review, we summarize and compare key recommendations for patients with CKD from the 2023 European Society of Hypertension (ESH), the 2024 European Society of Cardiology, the 2021 Kidney Disease: Improving Global Outcomes, and the 2025 American Heart Association/American College of Cardiology guidelines, with the aim of supporting clinicians in navigating guideline complexity and optimizing hypertension management in CKD.