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Management of hypertension in chronic kidney disease: the Italian multicentric study
L De Nicola1, R Minutolo, C Gallo
1Division of Nephrology, Second University of Napoli - Italy. luca.denicola@unima2.it
Insights
Most chronic kidney disease (CKD) patients do not reach blood pressure (BP) targets, indicating poor guideline implementation. Inadequate management of fluid overload, especially in older patients with diabetes, is a key barrier to achieving BP control in CKD.
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Internal Medicine
Background:
- Current guidelines prioritize blood pressure (BP) <130/80 mmHg for chronic kidney disease (CKD) patients.
- The practical implementation of these BP targets in clinical settings remains largely unassessed.
Purpose of the Study:
- To evaluate BP control rates in non-dialyzed CKD patients.
- To identify factors associated with failing to achieve BP targets.
- To assess current hypertension treatment strategies in CKD.
Main Methods:
- A cohort of 1201 adult non-dialyzed CKD patients was studied.
- Patients were followed by a nephrologist for at least 6 months.
- BP control, treatment, and clinical correlates of hypertension were assessed.
Main Results:
- 88% of CKD patients did not achieve the BP target (<130/80 mmHg).
- Elevated BP levels were persistent, with 84% above target at a prior nephrology visit.
- Older age, diabetes, and longer hypertension duration increased the risk of uncontrolled BP.
Conclusions:
- The majority of CKD patients in renal clinics do not reach BP targets.
- Inadequate management of extracellular volume is a likely barrier to guideline implementation.
- CKD patients, particularly older individuals with diabetes, exhibit heightened salt sensitivity, complicating BP management.
Background:
Guidelines have indicated the achievement of blood pressure target (BP <130/80 mmHg) as a priority in the conservative treatment of chronic kidney disease (CKD), but the current implementation of these recommendations in clinical practice is unknown.
Methods:
We assessed control rates, treatment and clinical correlates of hypertension in 1201 adult non-dialyzed CKD patients followed up by a nephrologist for at least 6 months.
Results:
Estimated glomerular filtration rate (GFR) was 32 (SD 15) mL/min/1.73 m2. BP target was not achieved in 88% of patients (95% confidence interval (95% CI): 86-90%). In 84% of patients, BP levels were also above the target at the first visit to the nephrology unit 4.5 yrs previously. The risk of not achieving BP target during the nephro-logy follow-up was associated with older age (odds ratio (OR): 1.24, 95% CI 1.06-1.45, p=0.008), diabetes (OR: 2.25, 95% CI 1.20-4.20, p=0.011), and the duration of hypertension (OR: 1.13, 95% CI 1.02-1.24, p=0.016). Among patients with uncontrolled BP, about 70% received multidrug antihypertensive therapy including renin-angiotensin system (RAS) inhibitors; conversely, diuretic treatment was prescribed in a minority of patients (37%), and at insufficient doses in half the cases, despite the insufficient implementation of a low salt diet (18%).
Conclusions:
BP target was not reached in most CKD patients routinely seen in the renal clinics. The main barrier to guideline implementation is possibly the inadequate treatment of extracellular volume expansion despite the large prevalence of factors, such as older age and diabetes, which further enhance the intrinsic BP salt sensitivity of CKD.
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