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Treatment of Resistant Hypertension in Pre-dialysis CKD
Patients
Definition of RH and Target BP According to Guidelines
The general definition of RH is largely applicable to the CKD population. Most of
the current guidelines, including those from the ESH/ESC 2013 [ 6 ], American
Society of Hypertension/International Society of Hypertension (ASH/ISH) 2014
[ 18 ], Eighth Joint National Committee (JNC 8) 2014 [ 19 ], American Heart
Association/American College of Cardiology/Centers for Disease Control and
Prevention (AHA/ACC/CDC) 2014 [ 20 ], Caring for Australasians with Renal
Impairment (CARI) 2013 [ 21 ], and Canadian Hypertension Education Program
(CHEP) 2014 [ 22 ], recommend a BP goal for these patients <140/90 mmHg, but
some suggest a lower target (<130/80 mmHg) for the subgroup with proteinuria [ 6 ,
18 , 21 ].
Triple Therapy
The triple regimen ACD seems to be a reasonable choice for patients with CKD and
difficult-to-treat hypertension.
The efficacy/safety of the ARB olmesartan (OM) 40 mg, the CCB amlodipine
10 mg (AML), and the diuretic hydrochlorothiazide 25 mg (HCTZ) versus the com-
ponent dual combinations (OM/AML, OM/HCTZ, and AML/HCTZ) was evaluated
in participants with diabetes, CKD, or cardiovascular diseases in the Triple Therapy
with Olmesartan Medoxomil, Amlodipine, and Hydrochlorothiazide in Hypertensive
Patients Study (TRINITY) [ 23 ]. At 12 weeks, OM/AML/HCTZ resulted in signifi-
cantly greater systolic BP reductions in participants with CKD. The BP goal
achievement was greater for participants receiving triple-combination treatment
compared with the dual-combination treatments. At week 52, there was sustained
BP lowering with the OM/AML/HCTZ regimen. Overall, the triple combination
was well tolerated.
Although RCTs comparing it with other triple therapies have never been per-
formed, the ACD combination is thought to be scientifically sound, effective, and
well tolerated, and it is widely used in everyday clinical practice. It should be tried
in optimum doses as the first therapeutic step in patients with CKD and RH, in the
absence of contraindications and after all forms of pseudo-resistance have been
excluded. This regimen might be applied in terms of switching previous therapy or
of treatment intensification in patients already using this combination in lower
doses [ 3 ].
L. Segall