Just hot off the press from the JAMA Internal Medicine ……. is the release of the results demonstrating all-cause mortality benefits by intensively lowering blood pressure in patients with chronic kidney disease (stage 3-5). In this study, patients in the more intensive lowering group had 14% lower risk of all-cause morality than the less intensive group (odds ratio 0.86; 95% CI 0.76-0.97, p=0.01)
In this study, patients were started off with a mean baseline systolic blood pressure of 148 mmHg. The more intensive lowering group were able to reduce the systolic blood pressure by 16mmHg (to 132mmHg), whereas the less intensive group lowered the systolic blood pressure by 8mmHg (140mmHg)
There is no doubt that lowering blood pressure is beneficial on many levels – it reduces the cardiovascular risk, the stroke risk, and risk of other complications due to end organ damages (e.g. vision impairment, kidney impairment).
In my experience, I often fear that the treatment options for hypertension in patients with renal impairment would be limited. For instance, many ACE-inhibitors require dosage adjustment with CrCL below 30mL/min, diuretics such as hydrochlorothiazide may have reduced efficacy in advanced renal impairment. Hence when it comes to optimizing antihypertensives in individuals with renal impairment, I often find it challenging.
But I also learned few new things from this article, entitled Management of Hypertension in CKD, Beyond the Guidelines by Judd and Calhoun. The authors recommend that the mainstay of anti-hypertensive treatments should include either an ACE-inhibitor or an ARB blocker. Diuretic therapy is often necessary, especially a combination of thiazide and a loop diuretic for patients with excess volume.
The authors also highlight the importance of salt restriction and potentially night-time antihypertensive medication dosing. The rationale for night time antihypertensive medication dosing is that a fall in nocturnal blood pressure is a normal part of the circadian pattern of blood pressure. Individuals where their blood pressure readings do not drop, or rise at night are at increased risk of death. Hence, dosing at least one antihypertensive at night time may offer protective and survival benefits.
So next time when I see an individual with chronic kidney disease and escalating blood pressure readings, I may suggest taking one of the antihypertensive at night and salt restriction….before I put on my thinking head to decide what antihypertensive agent to add to the list.
Do you have any experience with managing patients with hypertension and chronic kidney disease? I would love to hear from you.
Thank you for reading my post.