1、Hypertension In Chronic Kidney Disease,Renal disease,loss of nephrons,Systemic hypertension,Proteinuria,Progressive declinein GFR,Introduction,RENAL INJURY,Nephron mass Glomerular capillary hypertension Glomerular permeability to macromolecules Filtration of plasma proteins Proteinuria Excessive tub
2、ular protein reabsorbtion Tubulo-interstitial inflammation,RENAL SCARRING,SYSTEMIC HYPERTENSION,CKD: Common pathway in disease progression,Therapeutic intervention inhibiting this common pathway may succeed in slowing the rate of progression of CRF irrespective of the initiating cause,CKD: Common pa
3、thway in disease progression,Relative risk of ESRD according to quintile BP,MRFIT study N= 332,544 men,How important is systemic blood pressure control?,Treatment goal for hypertension in the general population has remained relatively the same for the last decade.,What should be the treatment goal?,
4、Should be lower than the general populationShould be tailored according to :,What should be the treatment goal for renal disease?,the severity of renal failurethe severity of the proteinuria,Aggressive BP control to 125/75 mmHg showed better preservation of GFR for those with proteinuria 3g/day.No a
5、dditional benefit if proteinuria is 1g/day,Klahr S, Levey AS: NEJM 1994; 330:877,Proteinuria and target BP control,What should be the treatment goal for renal disease?,Treatment goal should depend on the severity of proteinuria,What should be the treatment goal for non diabetic renal disease?,There
6、is indisputable evidence from animal, laboratory and clinical studies that proteinuria per se contributes to progressive renal injury,Proteinuria,Proteinuria and renal disease progression,Klahr S, Levey AS: NEJM 1994; 330:877,Proteinuria and renal disease progression,REIN SUBSTUDY : Progression of r
7、enal disease according to severity of proteinuria,It is now clear that different classes of antihypertensive agents have different antiproteinuric capacityACEI and ARB have been showed to exhibit the highest capacity to diminish protein excretion in urine,Proteinuria and renal disease progression,RE
8、IN Study : KIDNEY SURVIVAL,ACE Inhibitors In Nephropathy,P=0.04,REIN Study,ACE Inhibitors In Nephropathy,COOPERATE STUDY: Median urinary protein excretion,ACEI, ARB and combination treatment in Nephropathy,ACEI, ARB and combination treatment in Nephropathy,COOPERATE STUDY: proportion reaching endpoi
9、nts,ACEI or ARB should be the first choice antihypertensive agent in patient with significant proteinuria.,Choice of antihypertensive agent for non diabetic renal disease,Dose of ACEI or ARB should be titrated to achieve both target BP and the disappearance of proteinuria,Choice of antihypertensive
10、agent for non diabetic renal disease,If target blood pressure is not achieved and especially in the presence of persistent proteinuria, an ARB should be added.,Choice of antihypertensive agent for non diabetic renal disease,Check Cr and K+ within 7-14 days after starting treatment especially in the
11、presence of renal impairmentAn acute rise in Cr of 30% should be tolerated if BP is adequately reduced (140/90), hyperkalaemia is absent and the patient is euvolaemicIf Cr continues to rise, or hyperkalaemia persist, stop drugs; assess for bilateral RAS,Precautions when starting ACEI or ARB,Choice o
12、f combination antihypertensive agents depend on the existing comorbidity,Choice of antihypertensive agent for non diabetic renal disease,Drug(s) for the compelling indication,Choice of Anti-Hypertensive drugs in patient with concomitant disease,Since studies have demonstrated that most hypertensive
13、patients will require multiple drugs to achieve target BP, the argument about which one is superior has become almost irrelevant We must provide all of the drugs needed to achieve maximal protection with the fewest adverse effects,Choice of antihypertensive agent for non diabetic renal disease,Control Blood Pressure,Summary,Choice of antihypertensives,Summary,
