Management of hypertension in chronic kidney disease

  • Pasquale Zamboli
  • Luca De Nicola
  • Roberto Minutolo
  • Valerio Bertino
  • Fausta Catapano
  • Giuseppe Conte
Article

Abstract

Optimal blood pressure control (<130/80 mm Hg) in patients with chronic kidney disease (CKD), despite being the main objective of conservative therapy, is rarely achieved in clinical practice. A major area of improvement is the correction of the extracellular volume expansion. This goal can be reached by means of dietary salt restriction (≤Ü100 mEq/d of NaCl). If this intervention fails, hypertension can be treated by thiazide diuretics in patients with mild CKD, whereas loop diuretics at adequate doses are indicated in patients with more advanced CKD. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are more effective than other drugs in slowing progression of proteinuric diabetic and nondiabetic CKD. However, the control rates of blood pressure are usually inadequate with antihypertensive therapy including only these drugs; therefore, addition of other classes of antihypertensive drugs is often required.

References and Recommended Reading

  1. 1.
    De Nicola L, Minutolo R, Chiodini P, et al.: Global approach to cardiovascular risk in chronic kidney disease: reality and opportunities for intervention. Kidney Int 2006, 69:538–545. This is the largest recent systematic survey on the implementation of therapeutic goals in a population of CKD patients regularly followed by nephrologists in the real world of clinical practice.PubMedCrossRefGoogle Scholar
  2. 2.
    Buckalew VM Jr, Berg RL, Wang SR, et al.: Prevalence of hypertension in 1,795 subjects with chronic renal disease: the modification of diet in renal disease study baseline cohort. Modification of Diet in Renal Disease Study Group. Am J Kidney Dis 1996, 28:811–821.PubMedGoogle Scholar
  3. 3.
    Bakris GL, Weir MR, Shanifar S, et al.: Effects of blood pressure level on progression of diabetic nephropathy: results from the RENAAL study. Arch Int Med 2003, 163:1555–1565.CrossRefGoogle Scholar
  4. 4.
    Jafar TH, Stark PC, Schmid CH, et al.: Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Inter Med 2003, 139:244–252.Google Scholar
  5. 5.
    Bakris GL, Williams M, Dworkin L, et al.: Preserving renal function in adults with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis 2000, 36:646–661.PubMedGoogle Scholar
  6. 6.
    De Nicola L, Minutolo R, Bellizzi V, et al.: Achievement of target blood pressure levels in chronic kidney disease: a salty question? Am J Kidney Dis 2004, 43:782–795.PubMedCrossRefGoogle Scholar
  7. 7.
    Sarnak MJ, Levey AS, Schoolwerth AC, et al.: Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation 2003, 108:2154–2169. This review identifies and extensively comments for the first time the relevance of CKD as major independent cardiovascular risk factor.PubMedCrossRefGoogle Scholar
  8. 8.
    Keith DS, Nichols GA, Gullion CM, et al.: Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. Arch Inter Med 2004, 164:659–663.CrossRefGoogle Scholar
  9. 9.
    Go AS, Chertow GM, Fan D, et al.: Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004, 351:1296–1305.PubMedCrossRefGoogle Scholar
  10. 10.
    Sarnak MJ, Greene T, Wang X, et al.: The effect of a lower target blood pressure on the progression of kidney disease: long-term follow-up of the modification of diet in renal disease study. Ann Int Med 2005, 142:342–351.PubMedGoogle Scholar
  11. 11.
    K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis 2004, 43(5 Suppl 1):S1–S290.Google Scholar
  12. 12.
    Marin R, Fernandez-Vega F, Gorostidi M, et al.: Blood pressure control in patients with chronic renal insufficiency in Spain: a cross-sectional study. J Hypertens 2006, 24:395–402.PubMedCrossRefGoogle Scholar
  13. 13.
    Bellizzi V, Scal. L, Terracciano V, et al.: Early changes in bioelectrical estimates of body composition in chronic kidney disease. J Am Soc Nephrol 2006, 17:1481–1487.PubMedCrossRefGoogle Scholar
  14. 14.
    Dorhout, Mees EJ: Volaemia and blood pressure in renal failure: Have old truths been forgotten? Nephrol Dial Transplant 1995, 10:1297–1298.Google Scholar
  15. 15.
    Vasawada N, Agarwal R: Role of excess volume in the pathophysiology of hypertension in chronic kidney disease. Kidney Int 2003, 64:1772–1779.CrossRefGoogle Scholar
  16. 16.
    He FJ, MacGregor GA: Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health. J Hum Hypertens 2002, 16:761–770.PubMedCrossRefGoogle Scholar
  17. 17.
    Cianciaruso B, Bellizzi V, Minutolo R, et al.: Renal adaptation to dietary sodium restriction in moderate renal failure resulting from chronic glomerular disease. J Am Soc Neprol 1996, 7:306–313.Google Scholar
  18. 18.
    Koomans HA, Roos JC, Dorhout Mees EJ, Delawi IM: Sodium balance in renal failure: A comparison of patients with normal subjects under extremes of sodium intake. Hypertension 1985, 7:714–721.PubMedGoogle Scholar
  19. 19.
    Di Iorio BR, Minutolo R, De Nicola L, et al.: Supplemented very low protein diet ameliorates responsiveness to erythropoietin in chronic renal failure. Kidney Int 2003, 64:1822–1828.PubMedCrossRefGoogle Scholar
  20. 20.
    Mishra SI, Jones-Burton C, Fink JC, et al.: Does dietary salt increase the risk for progression of kidney disease? Current Hypertens Rep 2005, 7:385–391.Google Scholar
  21. 21.
    Cianciaruso B, Bellizzi V, Minutolo R, et al.: Salt intake and renal outcome in patients with progressive renal disease. Miner Electrolyte Metab 1998, 24:296–301.PubMedCrossRefGoogle Scholar
  22. 22.
    Navis G, de Jong PE, Donker AJ, et al.: Moderate sodium restriction in hypertensive subjects: renal effects of ACE-inhibition. Kidney Int 1987, 31:815–819.PubMedGoogle Scholar
  23. 23.
    Bakris GL, Smith A: Effects of sodium intake on albumin excretion in patients with diabetic nephropathy treated with long-acting calcium antagonists. Arch Intern Med 1996, 125:201–204.Google Scholar
  24. 24.
    Houlihan C, Allen TJ, Baxter AL, et al.: Low-sodium diet potentiates the effects of losartan in Type 2 diabetes. Diabetes Care 2002, 25:663–671.PubMedCrossRefGoogle Scholar
  25. 25.
    Cianciaruso B, Capuano A, D’Amaro E, et al.: Dietary compliance to a low protein and phosphate diet in patients with chronic renal failure. Kidney Int Suppl 1989, 27:S173-S176.PubMedGoogle Scholar
  26. 26.
    Ritz E, Dikow R, Morath C, Schwenger V: Salt--a potential ‘uremic toxin’? Blood Purif 2006, 24:63–66.PubMedCrossRefGoogle Scholar
  27. 27.
    Brater DC: Diuretic therapy. N Engl J Med 1998, 339:387–395.PubMedCrossRefGoogle Scholar
  28. 28.
    Dal Canton A, Fuiano G, Conte G, et al.: Mechanism of increased plasma urea after diuretic therapy in uraemic patients. Clin Sci 1985, 68:255–261.Google Scholar
  29. 29.
    Vasavada N, Saha C, Agarwal R: A double-blind randomized crossover trail of two loop diuretics in chronic kidney disease. Kidney Int 2003, 64:632–640.PubMedCrossRefGoogle Scholar
  30. 30.
    Remuzzi A, Puntorieri S, Battaglia C, et al.: Angiotensin converting enzyme inhibition ameliorates glomerular filtration of macromolecules and water and lessens glomerular injury in the rat. J Clin Invest 1990, 85:541–549.PubMedCrossRefGoogle Scholar
  31. 31.
    Yoshioka T, Rennke HG, Salant DJ, et al.: Role of abnormally high transmural pressure in the permselectivity defect of glomerular capillary wall: a study in early passive Heymann nephritis. Circ Res 1987, 61:531–538.PubMedGoogle Scholar
  32. 32.
    Klosa N, Bakris G: Lessons learned from recent hypertension trials about kidney disease. Clin J Am Soc Nephrol 2006, 1:229–235.CrossRefGoogle Scholar
  33. 33.
    Lewis EJ, Hunsicker LG, Bain RP, Rhode RD: The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med 1993, 329:1456–1462.PubMedCrossRefGoogle Scholar
  34. 34.
    Barnett AH, Bain SC, Bouter P, et al.: Angiotensin-receptor blockade versus converting enzyme inhibition in type 2 diabetes and nephropathy. N Engl J Med 2004, 351:1952–1961.PubMedCrossRefGoogle Scholar
  35. 35.
    Brenner BM, Cooper ME, De Zeeuw D, et al.: Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001, 345:861–869.PubMedCrossRefGoogle Scholar
  36. 36.
    Lewis EJ, Hunsicker LG, Clarke WR, et al.: Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001, 345:851–860.PubMedCrossRefGoogle Scholar
  37. 37.
    Miyata T, van Ypersele de Strihou: Renoprotection of angiotensin receptor blockers: beyond blood pressure lowering. Nephrol Dial Transplant 2006, 21:846–849.PubMedCrossRefGoogle Scholar
  38. 38.
    Nakao N, Yoshimura A, Morita H, et al.: Combination treatment of angiotensin-II receptor blocker and angiotensinconverting-enzyme inhibitor in non-diabetic renal disease (COOPERATE): a randomized controlled trial. Lancet 2003, 361:117–124. This is the largest study of efficacy of combination therapy with CEI+ARB on prevention of CKD progression.PubMedCrossRefGoogle Scholar
  39. 39.
    Minutolo R, Balletta M, Catapano F, et al.: Mesangial hypercellularity predicts antiproteinuric response to dual blocked of RAS in primary glomerulonephritis. Kidney Int 2006, 70:1170–1176.PubMedCrossRefGoogle Scholar
  40. 40.
    Hou FF, Zhang X, Zhang GH, et al.: Efficacy and safety of benazepril for advanced chronic renal insufficiency. N Engl J Med 2006, 354:131–140.PubMedCrossRefGoogle Scholar
  41. 41.
    Rahman M, Pressel S, Davis BR, et al.: Renal outcomes in high-risk hypertensive patients treated with an angiotensinconverting enzyme inhibitor or a calcium channel blocker vs a diuretic: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Int Med 2005, 165:936–946.CrossRefGoogle Scholar
  42. 42.
    Wright JT, Agodoa L, Contreras G, et al.: Successful blood pressure control in the African American study of Kidney Disease and Hypertension. Arch Int Med 2002, 162:1636–1643.CrossRefGoogle Scholar

Copyright information

© Current Science Inc. 2006

Authors and Affiliations

  • Pasquale Zamboli
  • Luca De Nicola
    • 1
  • Roberto Minutolo
  • Valerio Bertino
  • Fausta Catapano
  • Giuseppe Conte
  1. 1.Division of NephrologyMed School-Second University of Naples at Incurabili HospitalNapoliItaly

Personalised recommendations