Resistant Hypertension in Chronic Kidney Disease

348

The general approach of the GP to a CKD patient with RH is summarized in

Fig. 22.1.

Special Considerations of CKD as a Cause of RH

and Implications for the GP

Some features of a patient with hypertension seem independent risk factors for the
refractoriness of hypertension. In a recent study, Modolo and colleagues [ 23 ] found
that white-coat effect, black race, and left ventricular mass index were independent
predictors of resistant hypertension. In an analysis of Framingham study cohort
[ 24 ], older age, presence of left ventricular hypertrophy, and obesity were deter-
mined as the strongest predictors of the lack of systolic blood pressure control.
Chronic kidney disease is much more common in the elderly, because glomeru-
lar filtration rate decreases as part of normal aging and comorbid conditions such as
diabetes mellitus, hypertension, and atherosclerosis are common among elderly
patients. Left ventricular hypertrophy is very frequent in patients with
CKD. Renovascular disease, both macro- and microvascular, is also very prevalent

CKD patient with RH

Search for secondary

causes of

hypertension if any

suggestive laboratory

or physical

examination findings.

Monitor whether to

reach target blood

pressure with ABPM or

HBPM

Special consideration on

Exclude White-coat

RH with ABPM

Rule out

nonadherence

Search for

exacerbating

causes.

-Drug dosage adjustment as

per GFR

-Retarding the progression of

CKD

-Caution with aldosterone

antagonist use

-Loop diuretics and/or

combination of loop/thiazide

True RH

Salt intake, volume

control, medication-

induced

hypertension

Fig. 22.1 General approach to resistant hypertension from a GP viewpoint. GPs should be in a
close contact with hypertension specialists and nephrologists. CKD chronic kidney disease, RH
resistant hypertension, ABPM ambulatory blood pressure monitoring, HBPM home blood pressure
monitoring, GFR glomerular filtration rate

Y. S o l a k