Treatment of hypertension in patients with nondiabetic chronic kidney disease

Abstract

Hypertension is highly prevalent in patients with chronic kidney disease (CKD). As either the cause or the consequence of CKD, hypertension is an important independent factor determining the rate of loss of renal function. Hypertension is also a significant independent risk factor for cardiovascular events in patients with CKD, the leading cause of their morbidity and mortality. Based on evidence from observational cohort studies and randomized clinical trials, the Canadian Hypertension Education Program (CHEP) recommends a target blood pressure (BP) of lower than 130/80 mmHg in hypertensive patients with nondiabetic CKD. The CHEP also endorses the use of renin-angiotensin system blockers for the BP-lowering regimen in nondiabetic patients with CKD and significant proteinuria. It is recognized that the majority of nondiabetic patients with CKD will require two or more BP-lowering drugs to attain target BP. Furthermore, extracellular fluid volume expansion is a major contributor to hypertension in patients with CKD, and diuretics should be part of the BP-lowering regimen in the majority of patients. Patients with CKD are recognized to be at high risk for cardiovascular events, and studies testing new emerging treatments of hypertension to reduce the burden of CKD on renal and cardiovascular outcomes are underway. In this regard, the CHEP will continue to review and update all its recommendations annually.

Figure 1)

The relative risk for kidney disease progression based on current systolic blood pressure and urine protein excretion. The relative risk for patients with a current protein excretion of 1.0 g/day or more represents 9336 patients (223 events), and the relative risk for patients with a current urine protein excretion of less than 1.0 g/day represents 13,274 patients (88 events). Modified from reference 9

Figure 2)

Age-adjusted risk for end-stage renal disease (ESRD) in the whole cohort and in subgroups stratified by race (black [n= 57,085], white [n=218,261]. The number of patients in different blood pressure strata were as follows: ≤120/80 mmHg (n=89,774), 120–129/80–84 mmHg (n=72,192), 130–139/85–89 mmHg (n=56,078), 140–159/90–99 mmHg (n=69,083), 160–179/100–109 mmHg (n=21,340), 180–209/110–119 mmHg (n=6626) and ≥210/120 mmHg (n=1582). Modified from reference 6

Figure 3)

Cumulative probability of end-stage renal disease in patients randomly assigned to usual blood pressure (BP) (mean arterial pressure lower than 107 mmHg) or low BP (mean arterial pressure lower than 92 mmHg in patients 60 years old or younger, or lower than 98 mmHg in those 61 years old or older) during the long-term follow-up of the Modification of Diet in Renal Disease (MDRD) trial. Modified from reference 7