191second step is to adjust the diuretic that patients should be taken before they are
diagnosed of resistant hypertension. In this regard, in advance chronic kidney dis-
ease a loop diuretic may be needed, and low-dose thiazide from combination pills
may be insufficient.
Once compliance has been achieved and diuretic therapy optimized, a next step may
be the addition of low-dose mineralocorticoid receptor blocker, although potassium
should be monitored and the patient provided with specific instructions to stop the
medication if they develop risk factors for acute kidney injury or hyperkalemia such as
dehydration. Special care is required for patients already under renin- angiotensin sys-
tem blockade, as it is frequent among chronic kidney disease patients [ 17 ].
Emphasis should be made on avoiding hypotension, especially orthostatic hypo-
tension, since it may result in falls that may bring the patient’s demise. In this regard,
24-h blood pressure monitoring is underused in this age range and may allow the
confirmation of hypotensive episodes that may not be reported by the patient.
Given the dismal outcome of patients with end-stage kidney disease [ 18 ], a care-
ful correction of all cardiovascular risk factors since the earliest stage of disease is
required to improve outcomes. In this regard, recognition and treatment of resistant
hypertension in the elderly with chronic kidney disease, which is the fastest growing
segment of chronic kidney disease patients, should be a key goal.
The Impact of SPRINT
The recently published Systolic Blood Pressure Intervention Trial (SPRINT) on
patients at high risk for cardiovascular events but without diabetes observed that
targeting a systolic blood pressure of less than 120 mmHg, as compared with less
than 140 mmHg, resulted in lower rates of fatal and nonfatal major cardiovascular
events and death from any cause, although significantly higher rates of some adverse
events [ 19 ]. The reduction in major cardiovascular events and all-cause mortality
with intensive blood pressure control was observed in older individuals, including
patients with chronic kidney disease and mild proteinuria [ 20 , 21 ]. This is likely to
impact clinical practice in the near future.
While there were no significant interactions between treatment and subgroup
with respect to the primary outcome, in subgroup analysis the elderly (≥75 years
old) obtained clear benefit with regard to the primary outcome (hazard ratio (95%
CI); 0.67 (0.51–0.86)). However, no significant benefit was observed in patients
with chronic kidney disease (0.82 (0.63–1.07)), while benefit was observed for
those without chronic kidney disease (0.70 (0.56–0.87)). Thus, it is unclear what the
effect in elderly patients with kidney disease might be. This population might be
more sensitive to certain adverse effects, such as acute kidney injury. In this regard,
in the overall population, there was a higher rate (more than double) of acute kidney
injury in the intensive-treatment group, which may be of particular concern for the
chronic kidney disease and elderly population. Furthermore, there are two caveats.
First, diabetics were excluded. Thus, results do not apply to the most frequent cause
12 Resistant Hypertension in Elderly People with Chronic Kidney Disease