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

2. Contents Prevalence Blood Pressure measurement Targets Management
Guidelines

3. 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

4. BP MEASUREMENT
Office BP
Ambulatory BP
Home BP

5. ABPM

8. Ambulatory BP in CKD

9. 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

10. Home BP monitoring in CKD

13. What about
SALT

15. Cont

17. LOW SALT CKD study

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

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

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

22. 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

24. 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

25. Albuminuria vs proteinuria

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

27. 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.

28. 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

29. 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

30. Comparison

31. JNC 8

33. 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

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

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

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

37. Controversies

40. Thank you !