Therapy of hypertension in kidney diseases

Abstract

The number of patients requiring chronic renal replacement therapy due to hypertension and diabetic nephropathy has increased steadily over the past decade in Switzerland. The level of blood pressure represents one of the major risk factors for the progression of renal diseases. Thus, treatment of hypertension is the cornerstone in the primary and secondary prevention of diabetic nephropathy and in particular in decreasing the rate of progression of chronic renal diseases. The WHO guidelines for the treatment of hypertension recommend a target blood pressure of < 130/80 mmHg for patients with renal failure and/or diabetes mellitus. Blood pressure should be lowered to < 125/75 mmHg in patients with proteinuria > 1 g/d and renal failure regardless of the etiology of the renal disease. Based on several intervention studies it is well established that antagonists of the renin-angiotensin system should be part of the antihypertensive regime in those patients. Besides their antihypertensive action, it has become evident that the renoprotective effect of these agents is also mediated by factors independent from changes in blood pressure. However, in most patients with chronic renal failure it is often necessary to use multiple drugs to lower blood pressure to target values. Often a combination of an ACE-inhibitor with a calcium-channel blocker is used for this purpose. The goal of the antihypertensive therapy in these patients is not only to lower blood pressure to reduce cardiovascular risk, but also to reduce proteinuria and to reduce the rate of loss in renal function or even prevent further progression.