Resistant Hypertension in Chronic Kidney Disease (CKD): Prevalence, Treatment Particularities, and Research Agenda
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RESISTANT HYPERTENSION (L DRAGER, SECTION EDITOR)
Resistant Hypertension in Chronic Kidney Disease (CKD): Prevalence, Treatment Particularities, and Research Agenda Panagiotis I. Georgianos 1 & Rajiv Agarwal 2
# This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2020
Abstract Purpose of Review To explore the prevalence, treatment particularities, and research agenda in the management of resistant hypertension among patients with chronic kidney disease (CKD). Recent Findings The prevalence of resistant hypertension is reported to be 2–3 times higher in patients with CKD than in the general hypertensive population. Based in part on the results of the PATHWAY-2 trial showing add-on spironolactone to be superior to placebo or active treatment with an α- or β-blocker in reducing BP, international guidelines recommend the use of spironolactone as fourth-line agent in pharmacotherapy of resistant hypertension. Despite the several-fold higher burden of resistant hypertension among patients with stage 3b–4 CKD, the use of spironolactone in this population has been restricted, mainly due to the risk of hyperkalemia. The recently reported AMBER trial showed that among patients with uncontrolled resistant hypertension and an estimated glomerular filtration rate of 25–45 ml/min/1.73m2, the newer potassium-binder patiromer prevented the development of hyperkalemia and increased the proportion of participants who remained on add-on spironolactone over 12 weeks of follow-up. Administration of spironolactone was associated with a clinically meaningful reduction of 11– 12 mmHg in unattended automated office systolic blood pressure (BP) over the course of the AMBER trial. Summary Newer potassium-binding therapies overcome the barrier of hyperkalemia and facilitate the persistent use of spironolactone, which is an effective add-on therapy to control BP in patients with resistant hypertension and advanced CKD. Future trials are now warranted to explore whether this strategy confers benefits on “hard” clinical outcomes in this high-risk population. Keywords CKD . Hyperkalemia . Patiromer . Resistant hypertension . Spironolactone
Introduction Resistant Hypertension: Definitions and Prevalence in the General Population Resistant hypertension is defined as blood pressure (BP) that remains uncontrolled despite the concurrent use of ≥ 3 classes This article is part of the Topical Collection on Resistant Hypertension * Rajiv Agarwal [email protected] 1
Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
2
Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, 1481 West 10th Street, Indianapolis, IN, USA
of antihypertensive medications or treatment with ≥ 4 classes of antihypertensive medications regardless of BP levels [1]. In 2018 [2], the American Heart Association (AHA) released an upda
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