What is your approach to managing patients with hypertensive crisis and avoiding brisk reductions in blood pressure and subsequent ischemic acute kidney injury?

In a hypertensive emergency, I find it challenging to tell if the worsening of kidney function is caused by the brisk reductions in blood pressure, or if the hypertensive emergency itself already did the damage to the kidney, and the "brisk" reduction in blood pressure may actually help it.

According to the American Heart Association (Bress et al., PMID 38804130), the goal should be a mean arterial pressure (MAP) decline of 20% to 25% over several hours. Drugs that can be used include labetalol, ...

This is an important topic in which terminology and associated definitions are critical because they directly influence management. Historically, hypertensive crisis has served as an umbrella term encompassing both hypertensive emergency and hypertensive urgency. However, accumulating evidence has demonstrated that acutely lowering blood pressure in patients with severe asymptomatic hypertension provides no proven benefit and may instead increase the risk of cerebral, coronary, and renal hypoper...

In my patients who tend to have some degree of renal dysfunction, I find myself using a lot of diuretics. In my experience, many of these patients are significantly volume overloaded. Diuretics tend to work the best to lower the blood pressure and do it in a slow fashion. Of course, if the blood pressure is extremely elevated or the patient is symptomatic, then ICU admission with intravenous therapy may be indicated.