349in this patient population. One of the increasingly recognized causes of treatment
resistant hypertension, obstructive sleep apnea syndrome, is also reported to be fre-
quent among patients with CKD [ 25 ]. Most of these risk factors and comorbid con-
ditions occurring in patients with CKD also lead to further deterioration of kidney
function. Additional decline in GFR in turn makes the control of blood pressure
more challenging. For instance, CKD was detected in 30% of patients with sleep
apnea syndrome [ 26 ]. Thus, CKD patient presents with factors which renders them
resistant to antihypertensive agents.
Thus, CKD patient with resistant hypertension is not just hypertensive due to
diminished GFR. In fact, these patients can harbor a number of concomitant disor-
ders simultaneously. Thus, detection and treatment or amelioration of these disor-
ders should be undertaken to achieve optimal blood pressure targets and retard the
progression of chronic kidney disease. GPs should carefully evaluate these patients
as part of the global cardiovascular risk assessment. For example, the presence of
obesity and snoring should prompt the GP to test for obstructive sleep apnea. Once
detected, specific expert recommendations should be sought for these disorders to
take the blood pressure under control as well as improving cardiovascular progno-
sis. In this regard, elderly patients with CKD and resistant hypertension may some-
times be very difficult to manage, and a team of special experts including a
nephrologist, a cardiologist, an endocrinologist, and a dietician may be needed to
optimize the care of the patient. However, GPs should be at the core of this team to
coordinate the recommendations of different disciplines, which may at times com-
plicate the others. GPs as the primary physicians of these patients should not only
be in a close cooperation with other specialists of the patients but also be familiar
with living environment of the patient and close relatives.
Treatment of RH in CKD from a General Practice Perspective
General principles of hypertension treatment also apply to the treatment of RH. Since
treatment of RH has been comprehensively evaluated in previous chapters, in this
chapter we will discuss the topic with a special emphasis on a general practice set-
ting to avoid redundancy. GPs should be knowledgeable about correct combinations
of antihypertensive medication classes in general. Sometimes, physician-induced or
iatrogenic pseudoresistant hypertension can be seen simply because of the use of
inadequate doses or wrong combinations of antihypertensive medications. Physician
inertia can be described as reluctance to maximize drug therapy, either by adding
antihypertensive drugs or by switching drug category, in order to achieve blood
pressure goals. Studies have shown that physician inertia is an important cause of
resistant hypertension [ 27 ]. This may be a significant concern especially in patients
with CKD when GP themselves feels uncomfortable with the complexity of the
patient or reluctant to change antihypertensive treatment regimen with fear of poten-
tial adverse effects. GPs should aim to reach maximally tolerated doses of proper
22 Resistant Hypertension and the General Practitioner (Monitoring and Treatment)