Specifičnosti u lečenju hipertenzije kod bolesnika sa hroničnim bubrežnim oboljenjem

Abstract

Today, it is believed that all over the world about 10% of the population has a kidney lesion, most often chronic kidney disease (CKD). Hypertension and diabetes mellitus are the most common causes of chronic kidney damage, and in everyday clinical practice, we often wonder whether hypertension is a consequence of a lesion of the kidney parenchyma and vasculature or is its cause. Patients with CKD have high cardiovascular (CV) morbidity and most often die from CV disease. The specificity of blood pressure treatment in patients with chronic kidney damage is that good control of hypertension not only leads to a reduction of CV risk but also to a slowing of the progression of chronic to terminal renal failure. There is no doubt that the first line of treatment for hypertension in patients with CKD is angiotensinconverting enzyme inhibitors (ACEi) and angiotensin-2 receptor blockers (ARB). They are recommended especially for those patients with diabetic nephropathy because, in addition to their antihypertensive effect, they reduce proteinuria, slow down the progression of chronic kidney failure, especially if given in the early stages of CKD, and reduce CV risk. However, for a long time, there have been controversial opinions about whether in the advanced stages of renal failure, when the glomerular filtration rate (GFR) is < 30 mL/min/1.73 m2, these drugs should be excluded. According to the latest KDIGO guidelines in 2021, renin-angiotensinaldosterone (RAAS) blockers are the first line in the treatment of proteinuric CKD patients, with and without diabetes mellitus, and in stage 4, with a note that these drugs should be continued in therapy unless there is marked hyperkalemia (potassium > 6 mmol/L), acute kidney damage or decrease in estimated glomerular filtration rate > 30%. The most important thing is to individualize the optimal therapy for each patient. In the guidelines for the treatment of hypertension in patients with CKD, there are no clear recommendations for the treatment of unregulated hypertension when target pressures cannot be achieved with RAAS blockade and when there are contraindications for the administration of this group of drugs. The addition of calcium channel blockers, diuretics, and beta blockers is based on expert opinion.