Resistant Hypertension and Chronic Kidney Disease

Rossignol P, Massy ZA, Azizi M, et al., on behalf of the ERA-EDTA EURECA-m Working Group, Red de Investigación Renal (REDINREN) Network, and Cardiovascular and Renal Clinical Trialists (F-CRIN INI-CRCT) Network.
The Double Challenge of Resistant Hypertension and Chronic Kidney Disease. Lancet 2015;386:1588-1598.

The following are key points to remember about the double challenge of resistant hypertension and chronic kidney disease:

  1. Resistant hypertension is defined as blood pressure (BP) above goal despite adherence to a combination of at least three optimally dosed antihypertensive medications, one of which is a diuretic.
  2. Chronic kidney disease is the most frequent of several patient factors or comorbidities associated with resistant hypertension. The prevalence of resistant hypertension is increased in patients with chronic kidney disease, while chronic kidney disease is associated with an impaired prognosis in patients with resistant hypertension.
  3. Low-salt diet and triple antihypertensive drug regimens that include a diuretic, should be complemented by the sequential addition of other antihypertensive drugs for those with resistant hypertension.
  4. Inadequate control of BP is often attributable to poor drug adherence. Inadequately controlled BP due to poor drug adherence is not strictly consistent with the definition of resistant hypertension, but it is one of the causes of apparent treatment-resistant hypertension.
  5. Complex multidrug therapeutic regimens increase the likelihood of drug-related side effects, which could contribute to nonadherence. When possible, fixed-dose combinations should be prescribed to reduce the pill burden, which might improve adherence to treatment in association with home BP monitoring, regular appointments, and involvement of healthcare professionals in conjunction with the patients and their family.
  6. Physicians can contribute to poor management of resistant hypertension in patients with chronic kidney disease through omission of salt-restriction recommendations, prescriptions for diuretics, or reluctance to increase the dose of BP medication.
  7. New therapeutic innovations for resistant hypertension such as renal denervation and carotid barostimulation are under investigation, especially in patients with advanced chronic kidney disease, and needs further study.
  8. Stronger commitment of policy makers through public health efforts (e.g., earlier diagnosis of resistant hypertension in chronic kidney disease, reduction of salt content in food, overcoming therapeutic inertia, promotion of polypills to facilitate drug adherence, dedicated reimbursement policies, and providing funding for home BP monitors) should be encouraged.

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention, Diet, Hypertension

Keywords: Antihypertensive Agents, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Diet, Sodium-Restricted, Denervation, Diuretics, Hypertension, Kidney Failure, Chronic, Metabolic Syndrome X, Primary Prevention, Renal Insufficiency, Chronic, Sodium Chloride, Dietary

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