Current perspectives for hypertension in chronic kidney disease: Where are we now, where we headed

초록

The progression of chronic kidney disease (CKD) is largely independent of the underlying kidney disorder once renal function has fallen below a critical level. Hypertension is an independent risk factor for disease progression in patients with kidney disorders. Hypertension and proteinuria are both markers and pathophysiological mechanisms of renal disease progression. Several randomized trials support a strong association between a systolic blood pressure (BP) less than 140 mm Hg and reduction of cardiovascular risk and CKD progression in patients with diabetes and no or low levels of albuminuria. The data supporting a target BP lower than 130/80 mm Hg are very weak for overall cardiovascular and CKD event reduction, however; they hold only for reduction of stroke risk among those with diabetes and for slowed CKD progression in those with a GFR less than 60 mL/min/1.73 m2 who have more than 300 mg per day of proteinuria. Increasing evidence from clinical trials indicates that the rate of CKD progression can be lowered by pharmacological interventions. The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for the management of (BP) in chronic kidney disease (CKD) provides the structural and evidence base for this guideline’s relevancy. While in general agreement to the 21 KDIGO guideline statements, nonpharmacological interventions should play a significant role in the management of hypertension in patients with CKD. The approach to the management of hypertension in elderly patients with CKD should be individualized and take into account comorbid conditions to avoid adverse outcomes from excessive BP lowering. In contrast to KDIGO, there is insufficient evidence to target a lower BP for nondiabetic CKD patients based on the presence and severity of albuminuria.