© Springer International Publishing AG 2017 283
A. Covic et al. (eds.), Resistant Hypertension in Chronic Kidney Disease,
DOI 10.1007/978-3-319-56827-0_18
Chapter 18
Treatment of Hypertension in Light of the
New Guidelines: Pharmacologic Approaches
Using Combination Therapies
Liviu Segall
Introduction
Resistant hypertension (RH) is very common in patients with chronic kidney disease
(CKD), with a prevalence of 20–35%, according to various studies [ 1 ].
Unfortunately, since individuals with advanced CKD and end-stage renal disease
(ESRD) have usually been excluded from randomized controlled trials (RCTs),
there is very little evidence to guide the pharmacological therapy of hypertension,
and particularly RH, in these patients [ 2 ].
Nevertheless, it is widely thought that the multifactorial pathogenesis of RH in
CKD requires multiple drug therapy, to simultaneously target factors like the intra-
vascular volume expansion and the hyperactivity of the renin-angiotensin system
(RAS) and the sympathetic nervous system [ 3 ]. Combined therapy, however, has to
be individualized, depending on the patient’s pathophysiologic profile, comorbidi-
ties, and contraindications. Moreover, the optimal combination should be well toler-
ated, to ensure long-term adherence [ 3 ]. Most antihypertensive agents available for
the general population can also be used in CKD patients, after consideration of their
metabolism and dosing adjustments according to the level of renal function [ 4 ]. The
pharmacological armamentarium includes diuretics, angiotensin-converting enzyme
inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel block-
ers (CCBs), beta-blockers (BBs), alpha-blockers, centrally acting drugs, and other
vasodilators [ 3 ] (Table 18.1).
L. Segall (*)
Nefrocare MS Dialysis Centre, Iaşi, Romania
e-mail: [email protected]