347Pressure natriuresis tries to compensate decreased salt excretion at the expense of
elevated systemic blood pressures. Increased salt intake also have detrimental
effects on vascular wall and kidney independent of its effects resulting from blood
pressure elevation [ 21 ]. Moreover, CKD renders individuals to be more salt sensi-
tive even if they were salt nonsensitive before the beginning of hypertension [ 11 ].
Owing to reasons specified above, salt restriction and volume control are crucial
points of management in an individual CKD patient with RH. GP should emphasize
the importance of salt restriction in the diet and monitor adherence of the patient to
salt-restricted diet.
General Approach to RH from a GP Perspective
Primary care physicians may have the chance to encounter both a patient who was
already diagnosed as RH at a tertiary referral center and a naïve patient whose RH
has been diagnosed by the GP. At both situations, a good communication with
hypertension specialists is a prerequisite for comprehensive and uninterrupted care
for the RH patient.
After diagnosing true RH and ruling out white-coat RH and nonadherence, the
GP also address the issue of salt intake as a potential cause and propagator of RH in
a CKD patient. If the GP excluded white-coat RH, and nonadherence, and con-
firmed correct combination of antihypertensive medications at maximally tolerated
doses, then he or she should look for secondary causes of RH. The prevalence of
resistant hypertension in patients with CKD is over 50% [ 22 ], and CKD is among
the causes of secondary hypertension. Investigation of all secondary causes nonse-
lectively may not be prudent and feasible in a primary care setting; thus, referral of
the patient for a specialized hypertension clinic for this reason may be required.
CKD perhaps is the most apparent cause of secondary hypertension owing to nearly
universal testing of serum creatinine and urinalysis in every patient with hyperten-
sion. Nevertheless, considering the high prevalence of CKD in the general popula-
tion, a patient might have both CKD and another underlying cause for his/her
RH. Thus, in the presence of specific laboratory and/or physical examination find-
ings suggestive of a specific cause of secondary hypertension, the presence of CKD
should not preclude investigation of these likely causes. Unlike the progressive and
mostly irreversible nature of CKD, many causes of secondary hypertension are
amenable to treatment and lead to cure or amelioration of hypertension.
Another responsibility of the GP at this point is to assess the overall risk of the
patient with RH in terms of total cardiovascular risk. And, as the holistic caregiver
of the patient, all other detected risk factors for CV disease such as diabetes and
dyslipidemia should be treated according to most current guideline recommenda-
tions. Every effort should be exerted to halt the progression of CKD. Because CKD
both is a cause and a consequence of elevated blood pressure, slowing the progres-
sion of CKD may be allowed to manage RH more effectively.
22 Resistant Hypertension and the General Practitioner (Monitoring and Treatment)