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and the motivation of the patient explored. This will save a lot of time and effort for
both patient and doctor. In the past, the best way to explore noncompliance with diet
or medication was to intern the patient. In our experience, most if not all patients
became hypotensive within a week of in-hospital low-salt diet and direct observed
of the intake of the medication that had been prescribed at home while “treatment
resistant.” The outcome was usually a reduction in the number of medications at
discharge and improved compliance.
In addition, the physician should be alert to signs and symptoms of additional
causes of secondary hypertension, atherosclerotic renal artery stenosis being one of
the most common in this context.
Finally, a 24-h urine collection should be used to assess sodium intake, if feasi-
ble, since elderly patients may have difficulty collecting urine.
Twenty-four hour monitoring of blood pressure will allow exclusion of white-
coat hypertension and disclose non-dipper night patterns characteristic of chronic
kidney disease patients that might benefit from chronotherapy. Among hypertensive
chronic kidney disease patients under nephrology care with a mean age of 65 years,
22% had true resistant hypertension patients (office blood pressure is ≥130/80
mmHg, despite adherence to ≥3 full-dose antihypertensive drugs including a
diuretic agent or ≥4 drugs and ambulatory average blood pressure ≥ 125/75 mmHg)
and 7% pseudoresistance (ambulatory average blood pressure < 125/75 mmHg).
Pseudoresistance was not associated with an increased cardiorenal risk, while true
resistance identified patients with the highest cardiovascular and renal risk [ 15 ].
A further concept is false isolated-office resistant hypertension (elevated clinic
blood pressure, controlled awake blood pressure means, but elevated asleep systolic
or diastolic blood pressure mean while treated with three hypertension medications
in a non-dipper pattern) which was present in 9% of patients with a mean age of 65
years treated with ≥3 hypertension medications and evaluated by 48-h ambulatory
blood pressure monitoring. These patients had higher prevalence of chronic kidney
disease. Thus, the classification of resistant hypertension patients into categories of
isolated-office resistant hypertension (i.e., with normal 24-h ambulatory blood pres-
sure) masked resistant hypertension (i.e., normal office blood pressure and abnor-
mal normal 24-h ambulatory blood pressure), and true resistant hypertension (i.e.,
both abnormal office blood pressure and abnormal normal 24-h ambulatory blood
pressure) cannot be based on the comparison of clinic blood pressure with either
daytime home blood pressure measurements or awake blood pressure mean from
ambulatory blood pressure monitoring, especially in the elderly plus chronic kidney
disease setting [ 16 ].
Therapeutic Approach
The therapeutic approach to the elderly patient with confirmed treatment-resistant
hypertension and chronic kidney disease relies first on promoting compliance.
While noncompliance associated apparent resistant hypertension is not really resis-
tant hypertension, achieving compliance is the first step in clinical practice. The
R. Fernández-Prado et al.