Management of Hypertension in Patients with Chronic Kidney Disease
Hypertension is the leading factor in the global burden of disease. It is the predominant modifiable risk factor for stroke, heart disease, and kidney failure. Chronic kidney disease (CKD) is both a common cause and sequel of uncontrolled hypertension. The pathophysiology of CKD-associated hypertension is complex and multi-factorial. This paper reviews the key pathogenic mechanisms of CKD-associated hypertension, the importance of standardized blood pressure (BP) measurement in establishing the diagnosis and management plus the significance of ambulatory BP monitoring for assessment of diurnal BP variation commonly seen in CKD. The optimal BP target in CKD remains a matter of discussion despite recent clinical trials. Medical therapy can be difficult and challenging. In addition to lifestyle modification and dietary salt restriction, treatment may need to be individualized based on co-morbidities. Combination of antihypertensive drugs, including appropriate diuretic choice and dose, is of great significance in hypertension management in CKD.
KeywordsHypertension Chronic kidney disease Blood pressure Ambulatory blood pressure monitoring Resistant hypertension
Compliance with Ethical Standards
Conflict of Interest
Dr. Hamrahian declares no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
- 1.World Health Organization. A global brief on hypertension: silent killer, global public health crisis. World health day 2013. Geneva: World Health Organization; 2013. p. 1–39.Google Scholar
- 2.Yoon SS, Fryar CD, Carroll MD. Hypertension prevalence and control among adults: United States, 2011–2014. NCHS data brief, no 220. Hyattsville, MD: National Center for Health Statistics. 2015.Google Scholar
- 5.Calhoun DA, Jones D, Textor S, Goff DC, Murphy TP, Toto RD, et al. Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association professional education committee of the Council for High Blood Pressure research. Hypertension. 2008;51:1403–19.CrossRefPubMedGoogle Scholar
- 14.Ciobanu AO, Gherghinescu CL, Dulgheru R, Magda S, Dragoi Galrinho R, Florescu M, et al. The impact of blood pressure variability on subclinical ventricular, renal and vascular dysfunction, in patients with hypertension and diabetes. Maedica (Buchar). 2013;8:129–36.Google Scholar
- 39.James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507–20.CrossRefPubMedGoogle Scholar
- 49.Drawz PE, Pajewski NM, Bates JT, et al. Effect of intensive versus standard clinic-based hypertension management on ambulatory blood pressure. Results from the SPRINT (systolic blood pressure intervention trial) ambulatory blood pressure study. Hypertension. 2017;69.Google Scholar
- 52.National Institute for Health and Care Excellence. Chronic kidney disease http://www.nice.org.uk/guidance/cg182/evidence/cg182-chronic-kidney-disease.
- 53.Dasgupta K, Quinn RR, Zarnke KB, Rabi DM, Ravani P, Daskalopoulou SS, et al. The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol. 2014;30:485–501.CrossRefPubMedGoogle Scholar
- 54.Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31:1281–357.CrossRefPubMedGoogle Scholar
- 55.Weber MA, Schiffrin EL, White WB, Mann S, Lindholm LH, Kenerson JG, et al. Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens. 2014;32:3–15.CrossRefPubMedGoogle Scholar
- 56.American Diabetes Association. Standards of medical care in diabetes. Chapter 8 ‘cardiovascular disease and risk management’. Diabetes Care. 2016;39(Suppl. 1):S60–71.Google Scholar
- 64.Dahlof B, Sever PS, Poulter NR, Wedel H, Beevers DG, Caulfield M, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomized controlled trial. Lancet. 2005;366:895–906.CrossRefPubMedGoogle Scholar
- 65.Patel A, MacMahon S, Chalmers J, Neal B, Woodward M, Billot L, et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomized controlled trial. Lancet. 2007;370:829–40.CrossRefPubMedGoogle Scholar
- 66.Chalmers J, Arima H, Woodward M, Mancia G, Poulter N, Hirakawa Y, et al. Effects of combination of perindopril, indapamide, and calcium channel blockers in patients with type 2 diabetes mellitus: results from the action in diabetes and vascular disease: Preterax and Diamicron controlled evaluation (ADVANCE) trial. Hypertension. 2014;63:259–64.CrossRefPubMedGoogle Scholar
- 78.Bakris GL, Sarafidis PA, Weir MR, Dahlöf B, Pitt B, Jamerson K, et al. Renal outcomes with different fixed-dose combination therapies in patients with hypertension at high risk for cardiovascular events (ACCOMPLISH): a prespecified secondary analysis of a randomised controlled trial. Lancet. 2010;375:1173–81.CrossRefPubMedGoogle Scholar
- 81.Williams B, MacDonald TM, Morant S, Webb DJ, Sever P, McInnes G, et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015;386:2059–68.CrossRefPubMedPubMedCentralGoogle Scholar
- 83.Rosendorff C, Lackland DT, Allison M, Aronow WS, Black HR, Blumenthal RS, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Hypertension. 2015;65:1372–407.CrossRefPubMedGoogle Scholar