Pharmacotherapy of hypertension in patients with pre-dialysis chronic kidney disease

ABSTRACT

Introduction

Hypertension is the most common co-morbidity in patients with chronic kidney disease (CKD), with prevalence gradually increasing across CKD Stages to the extent that about 90% of end-stage renal disease (ESRD) patients are hypertensives. Several factors contribute to blood pressure (BP) elevation and guide the therapeutic interventions that should be employed in these patients.

Areas covered

This review summarizes the existing data for the management of hypertension, regarding optimal BP targets and the use of major antihypertensive classes in patients with CKD.

Expert opinion

Management of hypertension in CKD requires both lowering BP levels and reducing proteinuria to minimize the risk of both CKD progression and cardiovascular disease. In this respect, aggressive control of office BP to levels <130/80 mmHg has long been proposed for patients with proteinuric nephropathies. Following evidence from recent studies that confirmed significant reductions in renal and cardiovascular outcomes with strict BP control, most, but not all, of international guidelines, suggest such BP goals for all hypertensive patients, including those with CKD. Use of renin-angiotensin system (RAS) blockers is the treatment of choice for patients with proteinuric nephropathies, while, in most patients with CKD, combination treatment with two, three, or more antihypertensive agents is often required to control BP.

KEYWORDS:

• Hypertension
• chronic kidney disease
• proteinuria
• antihypertensive drugs
• RAS-blockers

Article highlights

• Hypertension is the most common comorbidity accompanying CKD, and a major risk factor for cardiovascular events and mortality.

• Management of hypertension in advanced CKD with proteinuria involves not only reduction of BP levels but also reduction of proteinuria to decelerate CKD progression and decrease cardiovascular risk.

• Current evidence suggests that aggressive control of office BP to levels <130/80 mmHg should be targeted for all hypertensive patients, including those with CKD.

• The use of RAS-blockers is the cornerstone of hypertension treatment in patients with proteinuric nephropathies to slow the CKD progression.

• A combination of a RAS-blocker with additional antihypertensive agents, is almost always necessary to achieve adequate BP control in CKD. Calcium channel blockers, diuretics and β-blockers or second-line antihypertensive drugs may be used depending on the individual patient characteristics.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.