189African-American patients diagnosed as hypertensive nephropathy [ 14 ]. Since
hypertensive nephropathy is most frequently diagnosed in African-Americans, this
raises questions about any diagnosis of hypertensive nephropathy in other nephrop-
athies. In this regard, hypertensive nephropathy is a frequent diagnosis in the elderly
in whom no other cause of nephropathy is suspected not searched for. However
most likely, hypertensive nephropathy represents a nephropathy of unknown cause
that has slowly progressed under the radar since albuminuria is not routine assessed
in nondiabetics, and the threshold to diagnose chronic kidney disease based on
serum creatinine has been evolving over time. In this regard, chronic kidney disease
is by far the most frequent cause of secondary hypertension in the elderly and, con-
sequently, of treatment-resistant hypertension.
A high salt intake is, together with noncompliance, the most frequent cause of
apparent treatment-resistant hypertension. There are some trends that may impact
on both factors in elderly patients with chronic kidney disease. On one hand, both
the elderly and patients with chronic kidney disease progressively decrease their
dietary intake. A lower total dietary intake implies a low intake of most dietary
components, including salt. This would suggest that excessive salt intake would not
be expected to play a key role in apparent treatment-resistant hypertension in elderly
patients with chronic kidney disease. However, chronic kidney disease may limit
the ability of the kidney to excrete a salt load. In addition, it is difficult to start a
low-sodium diet at age 80 when this has not been part of your lifestyle for eight
decades. In this regard, malnutrition is a serious concern in elderly chronic kidney
disease patients and may limit the possibility to reduce dietary salt.
Prescription of multiple medications is frequent in the elderly, especially if they
have chronic kidney disease. This may negatively impact compliance. The problem
is magnified in healthcare systems that do not cover the full cost of medication,
since the elderly are frequently economically fragile.
Diagnostic Approach
The two essential steps in diagnosis treatment-resistant hypertension in the elderly
are to confirm the presence of uncontrolled hypertension by a 24-h blood pressure
monitoring to exclude white coat hypertension and a correct assessment of drug
prescription and compliance.
Assessment of compliance in the elderly is difficult since they may need helpers
that take care of the medication, and these helpers may not be present at the clinic
visit. However, this is a key element of the diagnostic approach, as in the absence of
compliance, blood pressure control will not improve despite multiple adjustments in
medication. Exploration of noncompliance should be cautious, and respectful, oth-
erwise we will get lies from the patient. The patient should perceive empathy and be
offered the opportunity to acknowledge noncompliance without feeling guilty. If
noncompliance is confirmed, a frank discussion should follow to understand the
motives, since only by understanding these issues will help prescribe drugs that the
patient will comply with. Specifically, the benefits of compliance should be emphasized
12 Resistant Hypertension in Elderly People with Chronic Kidney Disease