1、Hypertension in CKD,Michael J Casey, MD Wake Nephrology Associates,Hypertension Stats,HTN affects approximately 1 billion worldwide $500 billion in direct costs Continuous, consistent and independent relationship between BP and Cads For those age 40-70, each increased increment of 20/10 mmHg in BP d
2、oubles the risk of CVD across the entire BP range of 115/75 to 185/115. Only 35% of hypertensive patients on treatment are under control.,Hypertension as Defined by JNC VII,120/80 - normal; “optimal” 121-139/80-89 - “pre-hypertension” Controversial More a health policy statement 140-160/90-100 - Sta
3、ge 1 Hypertension 160/100 - Stage 2 Hypertension,Evaluation of the Hypertensive Pt,Age and rapidity of HBP onset Accurate measurement of BP Medication review Family History H/O CVD or kidney disease EtOH and tobacco Sleep history,Evaluation of the Hypertensive Pt,Evidence of Volume status Edema Hear
4、t & lung exam for CHF End Organ Damage Albuminuria/Proteinuria (MACR, 24 hr urine) LVH (ECG, Echo) CKD,Measurement of Blood Pressure,Seated position with arm supported ideal Allow patient to settle for several minutes Proper sized cuff Bladder to encircle 80 100% arm Bladder width 40-50% of arm Conf
5、irm 2 readings 5 minutes apart in both arms for initial diagnosis If taken in wrist or legs, the cuff must be at the level of the heart,BP Measurement,Home BP Monitoring,Self readings or continuous ambulatory monitoring Helpful adjunct to office readings More readings in patients usual environment B
6、etter correlated with cardiovascular outcomes Improves patient compliance Helps clarify symptoms Defines masked and white coat hypertension,Home BP Monitoring,Patients need to be taught proper methods No wrist cuffs Semi-automated electronic cuffs Cuff needs to be checked against office readings Fre
7、quency of monitoring can vary All current outcome data/guidelines/trails are from office readings,Ambulatory BP Monitoring,Ambulatory BP Monitoring,Ambulatory BP Monitoring,More reproducible than office measurements Helpful in early diagnosis Unexplained microalbuminuria or LVH White Coat Hypertensi
8、on Resistant Hypertension No long term studies yet,Prevalence of HTN in CKD,Hypertension in CKD,80% of patients with CKD have HBP Most start with essential hypertension As GFR decreases it is more dependent on salt/water retention from decreased GFR CKD patients also have derangements in the Renin/A
9、ngiotensin/Aldosterone system,Treatment of Hypertension,Goal depends on disease state 130/80 if DM, CKD, CVDz 125/75 if CKD with proteinuria SBP is the issue in the old Diastolic HBP is a problem of the young Reaching the target is more important than how you get there Multiple interventions are nec
10、essary in most,Hypertensive Emergencies,Hypertension is a chronic outpatient disease with rare acute side effects Headache, MS changes, ICH, Papilledema, CHF, Angina, Renal failure with hematuria, Hemorrhage are emergencies require hospitalization Otherwise treat asymptomatic severe HBP over days/we
11、eks Clonidine effective for outpatient acute BP lowering Hold ESA,Progression of CKD and BP,BP = CO X SVR BP = HR X Stroke Volume X SVR CO = cardiac output SVR = systemic vascular resistance,BP Formula,Lifestyle Modification First (Always),Low Salt (3 gm/day) DASH diet Exercise Tobacco Alcohol Sleep
12、 Apnea NSAIDS Decongestants Diet Pills,Renin inhibitors,RAAS Agents,ACE Inhibitors captopril, enalapril, lisinopril, ramipril Angiotensin Receptor Blockers losartan, irbesartan, valsartan, telmisartan Direct Renin Inhibitors - aliskiren Aldosterone Receptor Blockers spironolactone, eplerenone Drugs
13、of Choice in CKD Not in pregnancy,ACEI/ARB in CKD,Glomerular Perfusion,ACE Inhibitors,First class drug for all CKD patients Should be considered in all stages If tolerated then reduced development of ESRD, CKD progression Best outcome data in proteinuric CKD Angioedema and cough Hyperkalemia and wor
14、sening renal function,Angiotensin Receptor Blockers,Next choice after ACEI because of cost Equal outcome data at this point No Cough Same issues with hyperkalemia and ARF Combo with ACEI coming under fire,Direct Renin Inhibitors,Aliskiren (Tekturna) is only drug First new antihypertensive class in 1
15、5 years Promising renal/CHF data but no hard outcomes May be useful for proteinuria reduction in combo with ARB GI upset Same issue of hyperkalemia and ARF as with all RAAS agents,Aldosterone Blockers,Potassium sparing diuretics Can boost efficacy of loop diuretics Improves survival in CHF patients
16、Reduction in proteinuria +/- other RAAS agents Gynecomastia with spironolactone Same issue of hyperkalemia and ARF,Diuretics,Key to HBP management in non-ESRD CKD RAAS agent synergy Thiazides: hydrochlorothiazide; chlorthalidone, metolazone K-Sparing: amiloride, triamterene, spironolactone, eplereno
17、ne Loops: furosemide, bumetanide, torsemide,Thiazide Diuretics,JNC first choice BP med Very effective in multiple trials Often available in combo with RAAS agent Low K, increase BG, lipids at dose 25mg Ineffective at GFR 50 Can boost efficacy of loop diuretics,Loop Diuretics,Necessary to maintain vo
18、lume status in GFR 50 Furosemide is classic but short half life so poor for HBP Bumetanide is same but better absorbed Torsemide has much longer half-life and is my choice now that it is generic Titrate to increase UOP then increase frequency Low potassium is main issue, especially with thiazides (m
19、etolazone),Beta Blockers,Selective Beta Blockers Atenolol, metoprolol, bisoprolol, nebivolol Non selective Beta Blockers Propranolol Alpha Beta Blockers Labetolol, carvedolol,Beta Blockers,Next class in CKD patients Reduces HR, SV and also renin Reduces incidence of sudden cardiac death and arrhythm
20、ias Reduces CV events in CHF, post-MI Counter-acts reflex increase in HR/CO induced by vasodilators and diuretics,Beta Blockers,Carvedolol, labetolol are better for HBP Atenolol, metoprolol better for CHF, HR reduction and arrhythmia Propranolol for ascites/cirrhosis, anxiety Bradycardia and fatigue
21、 are main side effects,Central Adrenergic Agents,Clonidine is predominant drug Probably same benefits as b blockers No studies and never will be Synergy with b blockers debatable Dry mouth, fatigue, t.i.d., bradycardia Good for acute HBP/prn use Patch available Methyldopa for HBP in pregnancy,Dihydr
22、opyridine Calcium Channel Blockers,Nifedipine, amlodipine, felodipine Direct vasodilators Very effective prob 4th drug of choice Can cause peripheral edema especially in females No effect on HR, CHF Increase GFR, proteinuria,Glomerular Perfusion,Non-Dihydropyridine CCBs,Diltiazem and Verapamil Reduc
23、e HR and Lower BP Arrhythmia control Reduction in proteinuria but no renal outcomes Edema, bradycardia, gingival hyperplasia, CyP450 interactions,Other Vasodilators,Alpha blockers doxazosin, terazosin, prazosin Help with BHP Once daily Orthostatic hypertension, tachycardia, CHF Hydralazine Improved
24、outcomes in AA with CHF BID or TID Lupus syndrome Moderately effective,Minoxidil,Most potent antihypertensive agent Severe rebound tachycardia and edema Need beta blocker and loop diuretic Hair growth Pericarditis Inexpensive,Hypertension in ESRD,Great area of debate RAAS Agents and Beta blockers ma
25、y improve outcomes in non-RCTs What is correct measurement? Pre-HD BP Post-HD BP Home BP When to take/hold BP Meds,Hypertension in ESRD,Hypertension in ESRD,Hypertension in ESRD,Hypertension in ESRD,J-shaped curve of survival vs BP in ESRD Better survival with moderate HBP Only compared to other ESR
26、D ? Skewed by young patients ? Skewed by cardiomyopathy Most HBP is due to inadequate volume control Decrease interdialytic weight gain Challenge weight Longer HD times (daily, nocturnal, PD),Treatment of HBP in ESRD,Gradually challenge weight each HD No edema Cramping Low BP Management of intradial
27、ytic HBP UF profiling Na+ modeling Lower dialysate temperature Carnitene levels,Treatment of HBP in ESRD,Do not hold Beta blockers / Clonidine before dialysis (MY OPINION) Short acting meds Increase risk rebound HBP, Tachycardia Take once daily meds at bedtime for consistency from day to day Wean of
28、f meds without cardiovascular benefits,Treatment of HBP in ESRD,Treatment of HBP in ESRD,Treatment of HBP in ESRD,Treatment of HBP in ESRD,Small group of patients have BP rise with volume removal Exaggerated hormonal response decreased intravascular volume Manifest no edema BP normal at HD onset and
29、 usually within several hours after HD Benefit from increased DW/decreased UF Response to RAAS and Beta blockers,Summary,Hypertension is a complex disease High morbidity, mortality, economic impact Treatment is art + science RAAS agents key in CKD Volume regulation is crucial Scarce data on what to do in ESRD,THANK YOU,Brenda Martin Sun Tech ABPM Monitors ANNAPlease email me for a copy of my slides M,
