Management of hypertension in chronic kidney disease DR PRITAM GUPTA Senior Consultant & HOD Medicine Sunderlal Jain Hospital, Ashok Vihar Fortis Hospital, Shalimar Bagh, Delhi

Contents Prevalence Blood Pressure measurement Targets Management Guidelines

Prevalence India: 1.2 Billion population of CKD Incidence of ESRD is 229 (pmp) HTN: 85-95% in CKD (3-5) HTN: 2nd leading cause of ESRD in U.S

BP MEASUREMENT Office BP Ambulatory BP Home BP

ABPM

Ambulatory BP in CKD

ABPM in CKD Specific to CKD General advantages Better tool to predict renal & CV risk CKD progression, ESRD or death General advantages Multiple readings Dipping status White coat HTN Masked HTN

Home BP monitoring in CKD

What about SALT

Cont

LOW SALT CKD study

BP results Central SBP also significantly reduced Central Pulse pressure fell by 9 mmHg (p< 0.02) High Sodium Low Sodium Peripheral SBP 159 ± 14 148 ± 21 Peripheral DBP 87 ± 10 82 ± 12

CKD causes impaired salt excretion reduced renal mass sympathetic nervous drive RAAS imbalance altered NaCl handling in distal nephron endothelial dysfunction

High salt diet worsening of HTN increased TGF beta—— fibrosis impairs kidney autoregulation high glomerular filtration pressures— fibrosis

Objectives in Management of HTN Optimal BP control Slowing CKD progression Management of preexisting co-morbid conditions Prevention of new CV and cerebrovascular events Reduction in hospitalisations Longevity & healthy life

Lifestyle management Individualise BP targets Postural dizziness & hypotension Encourage lifestyle modification Achieving healthy weight ( BMI 20-25) Salt 5g/day (sodium 2g or 90 mmol) Exercise at least 30 min, 5/week Alcohol: max drinks 2 for males and 1 for females/day Stop Smoking

Albuminuria vs proteinuria

Adult CKD with/without diabetes Albuminuria (mg/day) BP target (mmHg) Preferred agent < 30 ≤140/90 None 30-300 ≤130/80 ACEI/ARB > 300

ACEI/ARBS—- MECHANISM OF ACTION FOR BP LOWERING Generalized arterial vasodilatation. Vasodilatation of the efferent and afferent glomerular arterioles, particularly the efferent, resulting in decreased intra-glomerular pressure and hence reduction in both GFR and urine albumin excretion. Reduction in adrenal secretion of aldosterone. — Aldosterone breakthrough. Inhibition of fibrosis. Enhancement of vascular and cardiac remodelling.

Renal transplant Native diseased kidneys Treat if BP > 130/80 CNI-cyclosporine, tac Steroids Pre-transplant HTN Donor HTN TRAS Chronic allograft injury Treat if BP > 130/80 Target < 130/80 Considerations Time post transplant CNI Persistent albuminuria Co-morbidities

Special populations in CKD Children Treat if BP > 90th percentile for age, sex & height Target < 50th percentile ACEI/ARBS Elderly Tailorise treatment Electrolytes AKI Orthostatic hypotension Drug side effects

Comparison

JNC 8

Night time dosing Reduced CV risk Improved 24 hr ambulatory BP control ADA 2013 guidelines- included level A recommendation to give 1 or more anti HTN drug at bedtime for DM

DIURETICS Loop diuretics - frusemide, torsemide Thiazides in high doses- chlorthalidone, indapamide, metolazone Mineralocorticoid antagonists- spironolactone, eplerenone, finerenone

Contd… CAUTION- do not start at eGFR< 30 ml/min watch out for hyperkalemia episodes of AKI

Others CCB- Cilinidipine, Amlodipine Alfa blockers- Prazosin, Terazosin Clonidine, Hydralazine Minoxidil Beta Blockers

Controversies

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