Antihypertensive therapy in chronic kidney disease: what targets and how to reach them

Abstract

Antihypertensive therapy in chronic kidney disease: what targets and how to reach them Abstract. The primary treatment target for lowering cardiovascular risk in chronic renal failure (as well as in the general hypertensive population) is to lower sitting office blood pressure. Since the physiological nocturnal blood pressure drop ("dipping") is frequently absent or even reversed in chronic renal failure (occasionally causing nocturnal blood pressures to be higher than at daytime), 24 hour blood pressure monitoring needs to be liberally used. Systolic office blood pressures should be 130 to 139 mm Hg, diastolic 80 to 89 mm Hg, and 24 hour blood pressures 10 mm Hg lower. In kidney diseases with relevant proteinuria (> 0.5 - 1.0 g / 24 h) and in diabetics with microalbuminuria (> 30 mg / 24 h), proteinuria reduction is an important second treatment goal, because this slows progressive loss of renal function. If there still is relevant proteinuria or (in diabetics, microalbuminuria) after reaching "cardiovascular" blood pressure goals, further lowering of blood pressure below 130 mm Hg systolic should be attempted, if tolerated. Orthostasis, syncope and diastolic blood pressures < 70 mm Hg must by all means be avoided. In addition, there is no demonstrable benefit of lowering systolic blood pressure < 130 mm Hg if eGFR is < 20 ml / min / 1.73 m2. Since intake and excretion of sodium chloride play a central role in the pathogenesis of hypertension in renal failure, habitual salt overconsumers (taking more than approximately 9 g NaCl / 24 h) need to reduce their intake. For the same reason, diuretics are mandatory components of antihypertensive treatment in chronic renal failure, even if there are no signs of volume expansion at all. At eGFRs < 30 ml / min / 1.73 m2, thiazide type diuretics should replaced or supplemented by loop diuretics (e. g. torasemide). SGLT2 inhibitors are adjuvant diuretics in diabetics with an eGFR > 30 ml / min / 1.73 m2. ACE inhibitors or angiotensin 2 receptor antagonists are only mandatory if proteinuria exceeds 0.5 to 1.0 g / 24 h (or in diabetics with microalbuminuria), but not generally in chronic renal failure. At least two antihypertensive drugs are almost always required; at least one should be taken in the evening.