malaysian society of nephrology ministry of health malaysia hypertension in chronic kidney disease
TRANSCRIPT
Malaysian Society of NephrologyMinistry of Health Malaysia
Hypertension In Chronic Kidney
Disease
Renal disease
loss of nephrons
Systemic hypertension
Proteinuria Progressive decline in GFR
Introduction
RENAL INJURY
Nephron massNephron massGlomerular capillary hypertensionGlomerular capillary hypertensionGlomerular permeability to macromoleculesGlomerular permeability to macromoleculesFiltration of plasma proteins Filtration of plasma proteins ProteinuriaExcessive tubular protein reabsorbtionExcessive tubular protein reabsorbtionTubulo-interstitial inflammationTubulo-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 pathway in disease progression
Relative risk of ESRD according to quintile BP
MRFIT studyN= 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.
Guidelines BP target
British Hypertension Society (2004) < 140/85
Malaysian Hypertension Society <140/90
JNC VII (2003) <140/90
What should be the treatment goal?
Should be lower than the general population
Should be tailored according to :
What should be the treatment goal for renal disease?
the severity of renal failure the severity of the proteinuria
Aggressive BP control to 125/75 mmHg showed better preservation of GFR for those with proteinuria >3g/day.
No additional benefit if proteinuria is < 1g/day
Klahr S, Levey AS: NEJM 1994; 330:877
0
2
4
6
8
10
fall
in
GF
R,
ml/
min
/yea
r
< 1 1 - 2.9 > 3
proteinuria, g/day
low BP
usual BP
Proteinuria and target BP control
Guidelines Target BP
British Hypertension Society (2004) <130/80
Malaysian Hypertension Society <130/80
JNC VII (2003) <130/80
What should be the treatment goal for renal disease?
Treatment goal should depend on the severity of proteinuria
Proteinuria (g/d) BP target (mm Hg)
>1 125/75
<1 130/80
What should be the treatment goal for non diabetic renal disease?
There is indisputable evidence from
animal, laboratory and clinical studies
that proteinuria per se contributes to
progressive renal injury
Proteinuria
Proteinuria and renal disease progression
0
2
4
6
8
10
fall
in
GF
R,
ml/
min
/yea
r
< 1 1 - 2.9 > 3
proteinuria, g/day
low BP
usual BP
Klahr S, Levey AS: NEJM 1994; 330:877
Proteinuria and renal disease progression
REIN SUBSTUDY : Progression of renal disease according to severity of proteinuria
It is now clear that different classes of antihypertensive agents have different antiproteinuric capacity
ACEI and ARB have been showed to exhibit the highest capacity to diminish protein excretion in urine
Proteinuria and renal disease progression
REIN 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 endpoints
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 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 presence of renal impairment
An acute rise in Cr of 30% should be tolerated if BP is adequately reduced (<140/90), hyperkalaemia is absent and the patient is euvolaemic
If Cr continues to rise, or hyperkalaemia persist, stop drugs; assess for bilateral RAS
Precautions when starting ACEI or ARB
Choice of combination antihypertensive agents
depend on the existing comorbidity
Choice of antihypertensive agent for non diabetic renal disease
Diuretic B-blocker ACE I ARB CCB Aldosterone antagonist
Heart failure
Post-myocardial infarction
High coronary risk
Diabetes
Chronic Kidney Disease
Recurrent stroke prevention
Drug(s) for the compelling indication
Concomitant Disease
Diuretics B-blockers ACEI Ca channel blocker
Alpha- blocker
ARB
Diabetes Careful careful yes yes yes yes
Gout No Yes Yes Yes Yes Yes/no
Hyperlipidaemia Careful Careful Yes yes yes yes
IHD Yes Yes Yes yes yes yes
Heart Failure Yes Careful Yes careful yes yes
Asthma Yes No Yes Yes yes yes
PVD Yes Careful Yes Yes yes yes
Renal Impairment Yes Yes Careful Yes yes Careful
Renal A Stenosis Yes Yes Careful Yes yes careful
Elderly with no co morbid cond.
yes yes yes yes yes yes
Choice of Anti-Hypertensive drugs in patient with concomitant disease
Since studies have demonstrated that most
hypertensive 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
Proteinuria (g/d) BP target (mm Hg)
>1 125/75
<1 130/80
Control Blood Pressure
Summary
Choice of antihypertensives
Kidney Disease Agents BP target
Diabetic Kidney Disease ACE inhibitors
or ARB
<130/80
Non diabetic kidney disease
Urine PCR
>200 mg/g
ACE inhibitors
Or ARB
<125/75
Non diabetic kidney disease
<200 mg/g
None preferred 130/80
Summary