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If the eGFR is found to be abnormal ( ie , less than 60mL / min / 1.73m 2 ), first validate the result with a repeat test , preferably within the next week , which facilitates the identification of rapidly evolving kidney injury . 17 If the value has continued to rapidly fall ( eg , it is now 20 % lower ), consider an acute kidney process and initiate a specific management plan . If the eGFR is still reduced , but not falling rapidly , monitor it again within three months , to confirm the diagnosis of CKD and establish the rate of kidney function decline that will determine future monitoring .
In the interim , consider additional investigations , including appropriate laboratory testing and imaging based on a targeted history and physical examination ( see box 2 ).
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TREATMENT OF CHRONIC KID- NEY DISEASE IN PATIENTS WITH HIGH BLOOD PRESSURE
ALL patients with CKD require multifactorial
treatment that includes lifestyle
modification , SGLT-2 inhibition and lipid lowering therapy , in addition to optimal blood pressure control ( see figure 7 ). Additional treatment ( s ) may then be added to ameliorate residual risks of kidney disease progression ( eg , persistent urinary albumin excretion ), heart failure and CVD .
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Figure 4 . Kidney health check . |
Chronic Kidney Disease Management in Primary Care ( 5th edition ). Kidney Health Australia , Melbourne , 2024 . |
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Goals for blood pressure lowering
Most people with high blood pressure
and CKD will not have adequate control of their blood pressure or be achieving recommended targets . A key component of their management is to improve blood pressure control , without unduly increasing the treatment burden , side effects or cost and their knock-on impact on adherence .
All patients with CKD should aim to achieve and maintain an office systolic blood pressure of less than 130mmHg to lower their risk of cardiovascular events and improve survival . 2 , 7 Figure 8 offers an algorithm for management of high blood pressure in CKD .
Once achieved , lower blood pressure targets may be appropriate to further lower cardiovascular risk in some individuals with elevated residual risks ( such as proteinuria , established CVD ) and good anticipated tolerability , balancing the key risks of syncope , falls and acute kidney injury ( AKI ). 22 , 23 However , once the systolic blood pressure
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is brought below 140mmHg , unlike cardiovascular outcomes , lower blood pressure targets may not be associated with improved kidney outcomes . 23
For example , it has been well documented that lower blood pressure targets improve cardiovascular outcomes , particularly reducing the risk of stroke . For example , the Systolic Blood Pressure Intervention Trial undertaken in adults with high blood pressure at increased cardiovascular risk was stopped early when it became clear that individuals randomised to a systolic blood pressure target of
60
Figure 5 . An eGFR less than 60mL / min / 1.73m 2 is abnormal .
less than 120mmHg had fewer cardiovascular events than those simply targeting a systolic blood pressure of less than 140mmHg . 24 Moreover , in a prespecified subgroup of 2646 participants with reduced eGFR at baseline ( eGFR 20-59 mL / min / 1.73m 2 ), this lower blood pressure target was also associated with a numerically lower incidence of the primary cardiovascular outcome ( hazard ratio 0.81 ; 95 % confidence interval 0.63-1.05 ) and reduced all-cause mortality ( hazard ratio 0.72 ; 95 % confidence interval 0.53-0.99 ). 25 However , kidney function
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decline was not slowed , and the incidence of impaired kidney function was actually increased , possibly due to increased risk of AKI . Similarly , the African American Study of Kidney Disease and Hypertension concluded that a lower blood pressure goal may not provide further benefit in slowing progression of kidney disease , except perhaps those ( high-risk patients ) with proteinuria . 26 This reinforces the hypothesis that in addition to better blood pressure control , patients with CKD also need other interventions to improve kidney outcomes . 2 , 17 |
CHOICE OF ANTIHYPERTENSIVE AGENT Almost all individuals with CKD will need treatment with multiple antihypertensive agents to achieve and maintain adequate blood pressure control . 19 Most will need a combination of three or more to achieve target blood pressure . 19 This means that consideration of which agent may be best is largely moot , overtaken with what will be the best combination for any individual . The most important feature is longterm adherence using easy regimens with few or no side effects . PAGE 30 |