Management of Hypertension in Chronic Kidney Disease

Abstract

Chronic kidney disease (CKD) is an increasingly prevalent condition globally and is strongly associated with incident cardiovascular disease (CVD). Hypertension is both a cause and effect of CKD and affects the vast majority of CKD patients. Control of hypertension is important in those with CKD as it leads to slowing of disease progression as well as reduced CVD risk. Existing guidelines do not offer a consensus on optimal blood pressure (BP) targets. Therefore, an understanding of the evidence used to create these guidelines is vital when considering how best to manage individual patients. Non-pharmacological interventions are useful in reducing BP in CKD but are rarely sufficient to control BP adequately. Patients with CKD and hypertension will often require a combination of antihypertensive medications to achieve target BP. Certain pharmacological therapies provide additional BP-independent renoprotective and/or cardioprotective action and this must be considered when instituting therapy. Managing hypertension in the context of haemodialysis and following kidney transplantation presents further challenges. Novel therapies may enhance treatment in the near future. Importantly, a personalised and evidence-based management plan remains key to achieving BP targets, reducing CVD risk and slowing progression of CKD.

Fig. 1

Pathogenesis and management flow-chart of hypertension in chronic kidney disease. ACEi angiotensin converting enzyme inhibitor, ARB angiotensin II receptor antagonist (blocker), CCB calcium channel antagonist (blocker), CKD chronic kidney disease, RAAS renin–angiotensin–aldosterone system

Fig. 2

Timeline of landmark randomised trials comparing standard with intensive blood pressure control. ACEi angiotensin converting enzyme inhibitor, BP blood pressure, CCB calcium channel antagonist (blocker), CVD cardiovascular disease, DBP diastolic blood pressure, eGFR estimated glomerular filtration rate, ESRD end-stage renal disease, MAP mean arterial pressure, MDRD Modification of Diet in Renal Disease, SBP systolic blood pressure, T2DM type 2 diabetes mellitus

Fig. 3

Factors contributing to the development of hypertension following kidney transplantation