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Treatment of Hypertension in Patients with Chronic Kidney Disease
Debbie L Cohen, MD
and Raymond R Townsend, MD
1. Assistant Professor of Medicine; 2. Professor of Medicine, Renal, Electrolyte, and Hypertension Division, University of Pennsylvania
Chronic kidney disease (CKD) is increasingly prevalent in the US. At least 85% of patients with stage 3 CKD or greater have hypertension.
Goal blood pressure is 130/80mmHg or less in most patients with CKD. A lower goal blood pressure of 125/75mmHg should be aimed for
in CKD patients with significant proteinuria. Most CKD patients will require at least three or four medications, if not more, to achieve these
goal blood pressures. Dosages, particularly of diuretics, may need to be adjusted in subjects with CKD. Side effects of medication such as
an acute increase in creatinine or hyperkalemia are more frequent in this population and clinical vigilance with appropriate biochemical
monitoring is necessary. Patients with CKD are more likely to die from cardiovascular disease before requiring dialysis or a kidney
transplant. As a result, CKD patients should be considered at high risk for cardiovascular disease. Aggressive management of blood
pressure in this population is vital.
Chronic kidney disease, hypertension
Disclosure: Debbie L Cohen, MD, provides speaker services for Boehringer Ingelheim. Raymond R Townsend, MD, has provided consultancy services for GSK, NiCox, and Roche and
has received research grants from the National Institutes of Health and Novartis.
Received: July 23, 2009 Accepted: September 16, 2009
Correspondence: Debbie L Cohen, MD, University of Pennsylvania, Renal, Electrolyte, and Hypertension Division, 1 Founders Building, 3400 Spruce Street, Philadelphia, PA 19104.
Chronic kidney disease (CKD) is increasingly prevalent, with an Pathogenesis of Hypertension in
estimated 26 million adults with CKD in the US.
Hypertension is the Chronic Kidney Disease
most common comorbidity in chronic kidney disease. At least 85% of A large and growing number of factors influence BP regulation in CKD,
patients with stage 3 CKD or greater have hypertension, making as shown in Table 1. Most of the increase in BP results from a subset of
parenchymal kidney disease the most common ‘secondary’ form of three primary systems, which include:
hypertension. Treatment of hypertension can often be challenging, as
these patients often have severe hypertension requiring the use of • salt retention;
multiple medications to achieve target blood pressure (BP) goals. • renin–angiotensin–aldosterone axis activation; and
Target BP goals are lower in patients with CKD than in the general • sympathetic nervous system activation.
population. Ideally, BP should be less than 130/80mmHg and
less than 125/75mmHg if patients also have significant proteinuria These factors are all potentially treatable and the physician should take
(>1g/ 24 hours). these into account when selecting medications in CKD patients.
How Common Is Hypertension in Salt Retention
Chronic Kidney Disease? Volume expansion is common in hypertension of CKD. As renal function
Hypertension is very common in CKD, with more than 80% of CKD declines, so does the ability to excrete sodium. If heart failure
patients having coexistent hypertension. Patients with more severe occurs, this adds to the challenge of maintaining euvolemia. Sodium
CKD are more likely to have more severe hypertension
that is more increases BP, so as kidney function declines it does so to an even greater
difficult to control, requiring a greater number of medications. extent than simple volume expansion would predict at the lowest levels
Conversely, patients with more severe hypertension are more likely to of kidney function.
This finding suggests that the effect of salt intake
The type of renal disease also influences the likelihood on BP as further kidney function loss occurs is likely to be enhanced by
of hypertension, and classically tubulo-interstitial diseases have had the CKD milieu. Moreover, salt administration is well known to abet the
less prevalence of elevated BP than glomerular diseases.
pro-hypertensive effects of angiotensin-II6 and norepinephrine.
54 © TOUCH BRIEFINGS 2009