Hypertension Management in Patients with Chronic Kidney Disease

Abstract

Hypertension and chronic kidney disease are closely linked. Patients with chronic kidney disease have hypertension almost universally and uncontrolled hypertension accelerates the decline in kidney function. The pathophysiology of hypertension in chronic kidney disease is complex, but is largely related to reduced nephron mass, sympathetic nervous system overactivation, involvement of the renin-angiotensin-aldosterone system, and generalized endothelial dysfunction. Consensus guidelines for blood pressure targets have adopted a blood pressure <120/80 mm Hg in native chronic kidney disease and <130/80 mm Hg in kidney transplant recipients. Guidelines also strongly advocate for renin-angiotensin-aldosterone system blockade as the first-line therapy.

Keywords: ambulatory blood pressure monitor; chronic kidney disease; hypertension; masked hypertension.

Figure 1

United States blood pressure guidelines for chronic kidney disease (CKD) hypertension targets over time. Above timeline: Hypertension trials with CKD participants from 1960 to 2018 (not all inclusive). Below timeline: Guidelines and hypertension treatment targets from 1960 to 2021. CKD: chronic kidney disease; AASK: African American Study of Kidney Disease and Hypertension; ACCORD: Action to Control Cardiovascular Risk in Diabetes; ADVANCE: The Action in Diabetes and Vascular Disease: Preterax and Diamicron Controlled Evaluation trial; HTN: hypertension; KDIGO: Kidney Disease Improving Global Outcomes; MDRD: Modification of Diet in Renal Disease; REIN-2: Blood-Pressure Control for Renoprotection in Patients with Non-diabetic Chronic Renal Disease; SPRINT: Systolic Blood Pressure Intervention Trial; SHEP: Systolic Hypertension in the Elderly Program; VA: Veterans Affairs. Adapted from Chang A et al. Blood Pressure Goals in Patients with CKD. CJASN Jan 2019, 14 (1) 161–169.