Treatment and Control of Hypertension Among Adults With Chronic Kidney Disease, 2011 to 2019

Abstract

Background: Hypertension frequently accompanies chronic kidney disease (CKD) as etiology and sequela. We examined contemporary trends in hypertension treatment and control in a national sample of adults with CKD.

Methods: We evaluated 5% cross-sectional samples of adults with CKD between 2011 and 2019 in the Veterans Health Administration. We defined CKD as a sustained estimated glomerular filtration rate value <60 mL/min per 1.73 m² or a urine albumin-to-creatinine ratio ≥30 mg/g. The main outcomes were blood pressure (BP) control, defined as a systolic BP <140 mm Hg and a diastolic BP <90 mm Hg based on the mean of monthly BP measurements, and prescriptions for antihypertensive medications.

Results: The annual samples ranged between n=22 110 and n=33 039 individuals, with a mean age of 72 years, 96% of whom were men. Between 2011 and 2014, the age-adjusted proportion of adults with controlled BP declined from 78.0% to 72.2% (P value for linear trend, <0.001), reached a nadir of 71.0% in 2015, and then increased to 72.9% by 2019 (P value for linear trend, <0.001). Among adults with BP above goal, the age-adjusted proportion who did not receive antihypertensive treatment increased throughout the decade from 18.8% to 21.6%, and the age-adjusted proportion who received ≥3 antihypertensive medications decreased from 41.8% to 36.3%. Prescriptions for first-line antihypertensive agents also decreased.

Conclusions: Among adults with CKD treated in the Veterans Health Administration, the proportion with controlled BP declined between 2011 and 2015 followed by a modest increase, coinciding with fewer prescriptions for antihypertensive medications.

Keywords: blood pressure; health services; hypertension; renal insufficiency, chronic.

Figure 1.. Trends in BP control between 2011 and 2019 among adults with chronic kidney disease treated in the Veterans Administration

Panel A. Age-adjusted proportion of adults with controlled blood pressure based on 2014 and 2020 VA/DoD guidelines Panel B. Age-adjusted proportion of adults with filled prescription for angiotensin converting enzyme inhibitors or angiotensin receptor blockers and filled prescription for thiazide diuretic Footnote to Panel A. Abbreviations: VA – Veterans Affairs, DoD – Department of Defense, BP – blood pressure The 2014 VA/DoD guidelines recommended a BP goal <140/90 mm Hg. The 2020 VA/DoD guidelines recommended a systolic BP goal <130 mm Hg. The data markers represent the age-adjusted observed proportion with BP control. The line segments were generated using joinpoint regression with a change at 2015. Applying the 2014 BP goals, BP control from 2011 to 2014 yielded a p-value <0.001; BP control from 2015 to 2019 yielded a p-value <0.001; the test for difference in trend lines before and after 2015 yielded a p-value <0.001. Applying the 2020 BP goals, BP control from 2011 to 2014 yielded a p-value <0.001; BP control from 2015 to 2019 yielded a p-value <0.001; the test for difference in trend lines before and after 2015 yielded a p-value <0.001. Footnote to Panel B. Abbreviations: ACEI – angiotensin converting enzyme inhibitor, ARB – angiotensin receptor blocker data markers represent the age-adjusted observed proportion with a prescription. The line segments were generated using joinpoint regression with a change at 2015. ACEI or ARB prescriptions from 2011 to 2014 yielded a p-value <0.001; ACEI or ARB prescriptions from 2015 to 2019 yielded a p-value <0.001; the test for difference in trend lines before and after 2015 yielded a p-value =0.04. Thiazide prescriptions from 2011 to 2014 yielded a p-value <0.001; thiazide prescriptions from 2015 to 2019 yielded a p-value <0.001; the test for difference in trend lines before and after 2015 yielded a p-value <0.001.