Prevalence of Apparent Treatment-Resistant Hypertension among Individuals with CKD

Tanner, Rikki M.; Calhoun, David A.; Bell, Emmy K.; Bowling, C. Barrett; Gutiérrez, Orlando M.; Irvin, Marguerite R.; Lackland, Daniel T.; Oparil, Suzanne; Warnock, David G.; Muntner, Paul

doi:10.2215/cjn.00550113

Cited by 136 publications

(96 citation statements)

References 24 publications

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“…6 As the age and sex distribution differ between the studies and because these are main drivers of the prevalence, a direct comparison of the findings is not possible, apart from the statement that (a)TRH is a fairly common phenomenon in clinical practice. In accordance with previous studies, 5,6 patients with aTRH CKD were shown to have a different clinical profile with more often a history of CVD and diabetes mellitus compared with patients with controlled BP. This has also been found in the general hypertensive population.…”

Section: Prevalencesupporting

confidence: 91%

“…In the population-based Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, aTRH was found in 25% of hypertensive patients with an eGFR of 45 to 60 mL/min and in 33% of those with an eGFR of <45 mL/min. 5 In the Chronic Renal Insufficiency Cohort (CRIC) study, hypertension was studied in patients with CKD without determining the prevalence of therapy resistance, but in the groups using 3 or 4 antihypertensive drugs, BP was uncontrolled (≥140/90 mm Hg) in 31% and 39%, respectively with almost 60% of patients with CKD using ≥3 antihypertensive drugs. 2 In the MASTERPLAN study, only patients with CKD under nephrologist care were included, thus adding that even in secondary care, prevalence of aTRH is high.…”

Section: Prevalencementioning

confidence: 99%

“…To date, little is known on this topic. 5,6 Moreover, new therapeutic options have emerged (renal sympathetic denervation and carotid barostimulation) for those difficult to treat. We aimed to study the prevalence of TRH in patients with CKD.…”

mentioning

confidence: 99%

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Prevalence of Apparent Therapy-Resistant Hypertension and Its Effect on Outcome in Patients With Chronic Kidney Disease

et al. 2015

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New options recently became available for treatment of uncontrolled blood pressure. Information on the prevalence of therapy-resistant hypertension (TRH) in patients with chronic kidney disease and its consequences is relevant to balance risks and benefits of potential new therapies. Data of 788 patients with chronic kidney disease came from a multicenter study investigating the effect on outcome of an integrated multifactorial approach delivered by nurse practitioners added to usual care versus usual care alone. Blood pressure was measured at the office and during 30 minutes using an automated oscillometric device. Apparent TRH (aTRH) was defined as a blood pressure ≥130/80 mm Hg despite treatment with ≥3 antihypertensive drugs, including a diuretic or treatment with ≥4 antihypertensive drugs. Participants were followed up for the occurrence of myocardial infarction, stroke or cardiovascular mortality (composite cardiovascular end point) and end-stage renal disease. aTRH was present in 34% (office blood pressure) and in 32% (automated measurements). During 5.3 years of follow-up, 17% of patients with aTRH reached a cardiovascular end point and 27% reached end-stage renal disease. aTRH lead to a 1.5-fold higher risk (95% confidence interval, 0.8–3.0) of a cardiovascular end point compared with controlled hypertensives in multivariable-adjusted analysis. aTRH increased end-stage renal disease risk 2.3-fold (95% confidence interval, 1.4–3.7). During 4 years of follow-up, the prevalence of aTRH did not decline in either treatment group. The prevalence of aTRH is high in patients with chronic kidney disease even after optimization of nephrologist care. The presence of TRH is related to a substantially increased risk of renal and cardiovascular outcomes.

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Section: Prevalencesupporting

confidence: 91%

Section: Prevalencementioning

confidence: 99%

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Prevalence of Apparent Therapy-Resistant Hypertension and Its Effect on Outcome in Patients With Chronic Kidney Disease

et al. 2015

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“…13 Among patients with CKD, an elevated ACR in the setting of normal eGFR was also associated with an increased prevalence of aTRH. Thus, aTRH and CKD are commonly comorbid.…”

Section: Ckd and Atrhmentioning

confidence: 99%

“…First, analysis of the SYM-PLICITY HTN-3 results reveals that office BPs changed by 214. 13 86 Second, there is currently no clinically available method for determining the efficacy of energy delivery in causing renal denervation. Although early animal and human studies have used norepinephrine spillover and muscle sympathetic nerve activity to document reductions in sympathetic tone after denervation, later studies, such as SYMPLICITY HTN-2 and SYMPLICITY HTN-3, have not used these tests because of their limited availability.…”

Section: Interventional Therapy: Device Based Sympathetic Modulationmentioning

confidence: 99%

Apparent Treatment-Resistant Hypertension and Chronic Kidney Disease: Another Cardiovascular-Renal Syndrome?

Vemulapalli

Tyson

Svetkey

2014

Advances in Chronic Kidney Disease

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To identify patients at increased risk of cardiovascular (CV) outcomes, apparent treatment-resistant hypertension (aTRH) is defined as having a blood pressure above goal despite the use of 3 or more antihypertensive therapies of different classes at maximally tolerated doses, ideally including a diuretic. Recent epidemiologic studies in selected populations estimated the prevalence of aTRH as 10% to 15% among patients with hypertension and that aTRH is associated with elevated risk of CV and renal outcomes. Additionally, aTRH and CKD are associated. Although the pathogenesis of aTRH is multifactorial, the kidney is believed to play a significant role. Increased volume expansion, aldosterone concentration, mineralocorticoid receptor activity, arterial stiffness, and sympathetic nervous system activity are central to the pathogenesis of aTRH and are targets of therapies. Although diuretics form the basis of therapy in aTRH, pathophysiologic and clinical data suggest an important role for aldosterone antagonism. Interventional techniques, such as renal denervation and carotid baroreceptor activation, modulate the sympathetic nervous system and are currently in phase III trials for the treatment of aTRH. These technologies are as yet unproven and have not been investigated in relationship to CV outcomes or in patients with CKD.

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Hypertension in Chronic Kidney Disease

Hamrahian

Falkner

2016

Advances in Experimental Medicine and Biology

131

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Hypertension, a global public health problem, is currently the leading factor in the global burden of disease. It is the major modifiable risk factor for heart disease, stroke and kidney failure. Chronic kidney disease (CKD) is both a common cause of hypertension and CKD is also a complication of uncontrolled hypertension. The interaction between hypertension and CKD is complex and increases the risk of adverse cardiovascular and cerebrovascular outcomes. This is particularly significant in the setting of resistant hypertension commonly seen in patient with CKD. The pathophysiology of CKD associated hypertension is multi-factorial with different mechanisms contributing to hypertension. These pathogenic mechanisms include sodium dysregulation, increased sympathetic nervous system and alterations in renin angiotensin aldosterone system activity. Standardized blood pressure (BP) measurement is essential in establishing the diagnosis and management of hypertension in CKD. Use of ambulatory blood pressure monitoring provides an additional assessment of diurnal variation in BP commonly seen in CKD patients. The optimal BP target in the treatment of hypertension in general and CKD population remains a matter of debate and controversial despite recent guidelines and clinical trial data. Medical therapy of patients with CKD associated hypertension can be difficult and challenging. Additional evaluation by a hypertension specialist may be required in the setting of treatment resistant hypertension by excluding pseudo-resistance and treatable secondary causes. Treatment with a combination of antihypertensive drugs, including appropriate diuretic choice, based on estimated glomerular filtration rate, is a key component of hypertension management in CKD patients. In addition to drug treatment non-pharmacological approaches including life style modification, most important of which is dietary salt restriction, should be included in the management of hypertension in CKD patients.

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Prevalence of Apparent Treatment-Resistant Hypertension among Individuals with CKD

Cited by 136 publications

References 24 publications

Prevalence of Apparent Therapy-Resistant Hypertension and Its Effect on Outcome in Patients With Chronic Kidney Disease

Prevalence of Apparent Therapy-Resistant Hypertension and Its Effect on Outcome in Patients With Chronic Kidney Disease

Apparent Treatment-Resistant Hypertension and Chronic Kidney Disease: Another Cardiovascular-Renal Syndrome?

Hypertension in Chronic Kidney Disease

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