Management of Hypertension in Chronic Kidney Disease
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THERAPY IN PRACTICE
Management of Hypertension in Chronic Kidney Disease Dan Pugh1,2 · Peter J. Gallacher1 · Neeraj Dhaun1,2
© The Author(s) 2019
Abstract Chronic kidney disease (CKD) is an increasingly prevalent condition globally and is strongly associated with incident cardiovascular disease (CVD). Hypertension is both a cause and effect of CKD and affects the vast majority of CKD patients. Control of hypertension is important in those with CKD as it leads to slowing of disease progression as well as reduced CVD risk. Existing guidelines do not offer a consensus on optimal blood pressure (BP) targets. Therefore, an understanding of the evidence used to create these guidelines is vital when considering how best to manage individual patients. Nonpharmacological interventions are useful in reducing BP in CKD but are rarely sufficient to control BP adequately. Patients with CKD and hypertension will often require a combination of antihypertensive medications to achieve target BP. Certain pharmacological therapies provide additional BP-independent renoprotective and/or cardioprotective action and this must be considered when instituting therapy. Managing hypertension in the context of haemodialysis and following kidney transplantation presents further challenges. Novel therapies may enhance treatment in the near future. Importantly, a personalised and evidence-based management plan remains key to achieving BP targets, reducing CVD risk and slowing progression of CKD.
Key Points
1 Introduction
Controlling hypertension in those with chronic kidney disease (CKD) not only slows progression of renal damage but reduces the risk of cardiovascular disease.
Chronic kidney disease (CKD) affects 10–15% of the population worldwide and its prevalence is increasing [1, 2]. CKD is defined as the presence of reduced kidney function (an estimated glomerular filtration rate [eGFR] 3
Relationship between measurement methods are not exact and will depend on multiple variables ACRalbumin-to-creatinine ratio, PCR protein-to-creatinine ratio
D. Pugh et al.
trials in CKD. Despite this, guidelines outlining optimal treatment for CKD patients with hypertension are important, particularly as many of these patients are jointly managed in primary care. In their 2017 guidelines, the ACC recommended that all adults with hypertension and CKD should be treated to a target BP of 1 g/day
1994
REIN-2 Interventions: DBP < 90 vs BP < 130/80 mmHg with addition of CCB Participants: Proteinuria > 1 g/day, eGFR < 70 mL/min/1.73 m2, non-diabetic, on ACEi Follow-up: 335 patients, median 1.6 years Results: No difference in time to ESRD
SPRINT Interventions: SBP < 140 vs < 120 mmHg Participants: eGFR > 20 mL/min/1.73 m2, nondiabetic, elevated CVD risk Follow-up: 9361 patients, median 3.3 years Results: Decreased CVD and death in intensive group
2002
2010
AASK Interventions: MAP 102–107 vs 97 mmHg Participants: eGFR 20–65 mL/min/1.73 m2, nondiabetic Follow-up: 1094 patients, minimum 3 years Results: Slowed eGFR decline in intensive group on
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