1. HTN & CKD 1

2. HTN has been reported to occur in 85-95% of patients with CKD (stages 3–5). The relationship between HTN & CKD is cyclic in nature. Uncontrolled HTN is a risk factor for developing CKD, is associated with a more rapid progression of CKD, & is the second leading cause of ESRD in the U.S. Progressive renal disease can exacerbate uncontrolled HTN due to volume expansion & increased systemic vascular resistance. 2

3. HTN & Progression of CKD Bakris et al. American Journal of Kidney Dise, Vol 36, 2000 3

4. Pathophysiology Brenner hypothesis (1981): Loss of autoregulation increase hyperfiltration increased Gp 4

5. GENERAL STRATEGIES Individualize BP targets & agents according to: Age Co-existent CVD & other co-morbidities Risk of progression of CKD Presence or absence of retinopathy (in DM) Tolerance of treatment Inquire about postural dizziness & check for postural hypotension regularly when treating CKD patients with BP-lowering drugs. Lifestyle & pharmacological treatments for lowering BP in CKD ND patients DEC 2012 5

6. Lifestyle & pharmacological treatments for lowering BP in CKD ND patients LIFESTYLE MODIFICATION Encourage LSM in patients with CKD to lower BP & improve long-term CV & other outcomes: Achieving or maintaining a healthy weight (BMI 20 to 25). Lowering salt intake to < 2 g/d of Na (corresponding to 5 g of NaCl), unless contraindicated. An exercise program compatible with CV health & tolerance, aiming for at least 30 minutes 5 times/week. Limiting alcohol intake to no more than 2 standard drinks/d for men & no more than 1 standard drink/d for women. DEC 2012 6

7. BP management in CKD ND patients without DM Adults with CKD ND & urine albumin excretion 140 mmHg systolic or > 90 mmHg diastolic be treated with BP-lowering drugs to maintain a BP that is consistently ≤ 140 mmHg systolic & ≤ 90 mmHg diastolic. Adults with CKD ND & urine albumin excretion of 30 to 300 mg/d whose office BP is consistently >130 mmHg systolic or > 80 mmHg diastolic be treated with BP-lowering drugs to maintain a BP that is consistently ≤130 mmHg systolic & ≤ 80 mmHg diastolic. Adults with CKD ND & urine albumin excretion > 300 mg/d whose office BP is consistently >130 mmHg systolic or > 80 mmHg diastolic be treated with BP-lowering drugs to maintain a BP that is consistently ≤ 130 mmHg systolic & ≤ 80 mmHg diastolic. ARB or ACE-I be used in non-diabetic adults with CKD ND & urine albumin excretion of > 30 mg/d in whom treatment with BP-lowering drugs is indicated. DEC 2012 7

8. Recommended Antihypertensive Agents for Patients With CKD & HTN Classification of Patients With CKD First LineSecond LineThird LineFourth Line Diabetic CKD with or without HTN ACEI or ARB Thiazide or loop diuretics ND-CCB (may 2nd line) Aldosterone antagonist Nondiabetic CKD + HTN + Pruria ACEI or ARB Thiazide or loop diuretics ND-CCB (may 2nd line) Aldosterone antagonist Nondiabetic CKD + HTN without Pruria (<200 mg/g) No agents preferred; consider a diuretic ACEI or ARB or CCB Aldosterone antagonist NA 8

9. CKD & HTN If patients are on more than 2 antihypertensive agents, it may be appropriate to administer 2 agents in the morning & the additional agents in the evening. Patients may often require 3-4 antihypertensive agents in order to achieve their goals & minimize their risk for CVD & ESRD. 9

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