32 HOW TO TREAT : HIGH BLOOD PRESSURE AND CHRONIC KIDNEY DISEASE
32 HOW TO TREAT : HIGH BLOOD PRESSURE AND CHRONIC KIDNEY DISEASE
8 NOVEMBER 2024 ausdoc . com . au
Figure 10 . Granular cast found during urine microscopy .
Ajay Kumar Chaurasiya / CC BY-SA 4.0 / bit . ly / 3VOgZaw
Box 3 . Referral to a specialist in kidney disease should be considered for individuals with :
• Suspected glomerulonephritis ( eg , in patients with chronic kidney disease and abnormal urine microscopy showing cellular casts ( see figure 10 ), non-urologic haematuria , sterile pyuria , or a personal history of systemic autoimmune disease ).
• Confirmed or presumed hereditary kidney disease , such as polycystic kidney disease , Alport syndrome , or autosomal dominant interstitial kidney disease .
• An eGFR less than 30mL / min / 1.73m 2 .
• An eGFR less than 60mL / min / 1.73m 2 and signs to suggest rapid progression : — Persistent urinary albumin to creatinine ratio 300mg / g ( 34mg / mmol ) or greater , or urine protein creatinine ratio 500mg / g ( 56.5mg / mmol ) or greater . — Anaemia . — Metabolic acidosis . — Hyperphosphatemia or hypocalcaemia . — Resistant hypertension despite at least three antihypertensive agents . — A recent fall in GFR greater than 5mL / min / 1.73m 2 in the past 12 months . — A single kidney on ultrasound . — Unexplained reduced kidney function in younger patients may also warrant consultation with a nephrologist . at increased risk of experiencing an acute decline in their kidney function . Once elevated albuminuria is established , repeat urinalysis is not usually required as ( once diagnosed with CKD ) it will not change the ( intensive ) disease management strategy that has already been initiated .
WHEN TO REFER TO A NEPHROLOGIST
MOST patients with stable impaired kidney function and high blood pressure can be safely and effectively managed in general practice . Most patients with stable , mild to moderate CKD and high blood pressure do not require nephrology evaluation , although they require serial monitoring to ensure
1 . Which THREE statements regarding high blood pressure and chronic kidney disease ( CKD ) are correct ? a Sustained elevated blood pressure is one of the most common causes of CKD . b Kidney function in CKD is irreversible . c It is usually easy to attribute the occurrence and / or progression of CKD solely to high blood pressure . d The appropriate blood pressure targets in those with CKD may be different from those recommended for the general population .
2 . Which TWO statements regarding high blood pressure and CKD are correct ? a These conditions often coexist and are clearly interrelated . b The prevalence of reported hypertensive CKD always correlates with that of high blood pressure in the same populations . c In Australia , a quarter of all patients that enter dialysis are reported as having hypertensive CKD . d The prevalence of high blood pressure increases in parallel with worsening stage of CKD and blood pressure is associated with a subsequent risk of kidney failure .
3 . Which THREE statements regarding the pathogenesis of CKD are correct ? that this course continues to be justified .
However , advanced CKD can be associated with a range of complications that require specialist management . Individuals with severely impaired kidney function ( eGFR less than 30mL / min / 1.73m 2 ) or at highrisk of developing it soon ( see box 3 ) should be considered for consultation and where appropriate , timely referral
2 , 15 , 17 to specialist services .
PROGNOSIS OF HYPERTENSIVE CHRONIC KIDNEY DISEASE
HIGH BLOOD PRESSURE and CKD commonly coexist and the
How to Treat Quiz .
a Arteriolosclerosis and vascular stiffening are early pathological changes . b Nephrosclerosis is specific to and / or diagnostic of hypertensive kidney damage . c The extent of glomerular sclerosis correlates with the progressive decline in kidney function . d The kidney has little or no regenerative capacity .
4 . Which TWO investigations are recommended for screening for CKD in patients with high blood pressure ? a Urine dipstick . b Urinary albumin to creatinine ratio . c HbA1c . d eGFR .
5 . Which THREE additional investigations should be considered in any patient initially presenting with impaired kidney function ? a FBC . b Screening for unrecognised diabetes . c Urine microscopy . d Repeat eGFR within one week .
6 . Which TWO statements regarding treatment of high blood pressure and CKD are correct ? relationship between these two pathophysiological states is bidirectional . 1 , 2 Persistently high blood pressure can accelerate the progression of CKD and the progressive decline in the eGFR can conversely interfere with the achievement of adequate blood pressure control . 2 The coexistence of uncontrolled high blood pressure and CKD substantially magnifies the risk of CVD , heart failure and sudden cardiac death . 3 These are the most important cause of morbidity and mortality in patients with CKD . However , CKD also increases the risk of poor clinical outcomes including reduced survival in other serious illnesses , including COVID-19 , sepsis , cancer and falls / fractures . Most
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a Most individuals with CKD will need a combination of two or more antihypertensive agents to achieve target blood pressure . b Aim for a systolic blood pressure as low as tolerated . c Beta blockers are contraindicated in patients with CKD . d The most important feature is long-term adherence using easy regimens with few or no side effects to control blood pressure .
7 . Which THREE statements regarding treatment of high blood pressure and CKD are correct ? a Guidelines recommend that all people with high blood pressure and CKD are treated with a high potency statin in the highest dose tolerated by that individual . b SGLT-2 inhibitors lower the risk of declining kidney function and kidney failure in people with CKD . c Guidelines recommend all people with CKD at increased risk of kidney failure are considered as candidates for SGLT-2 inhibition , including non-diabetic individuals .
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HIGH BLOOD PRESSURE AND CHRONIC KIDNEY DISEASE
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• Each article has been allocated one hour by the RACGP and ACRRM .
• RACGP points are uploaded every six weeks and ACRRM points quarterly . people with high blood pressure and CKD succumb to these other illnesses , rather than surviving to reach ESKD . Patient prognosis is dependent on numerous factors including age , ethnicity and comorbidity , together with risk factor control .
CASE STUDY
MARK , 56 , is an engineer who was initially diagnosed with high blood pressure five years ago . His GP has been managing him with an ARB and a thiazide diuretic . A routine blood test taken at his most recent visit shows his GFR is now 58mL / min / 1.73m 2 . Looking back , it was 70mL / min / 1.73m 2 three years ago , and he was documented to have
d Mineralocorticoid receptor antagonists may be associated with hypokalaemia , acute kidney injury and hypotension .
8 . Which TWO statements regarding treatment of high blood pressure and CKD are correct ? a GLP-1 receptor agonists in people with T2DM and CKD do not slow the decline in kidney function . b Sick day rules when to pause medication use are highly relevant in the setting of CKD . c Encourage patients to undertake 30 minutes of moderate intensity exercise per week . d Regular review and continuity of care from the same GP increases the likelihood of achieving target blood pressure .
9 . Which THREE may be indications for referral to a nephrologist ? a Stable impaired kidney function and high blood pressure . b Confirmed or presumed hereditary kidney disease . c An eGFR of less than 30mL / min / 1.73m 2 . d An eGFR of less than 60mL / min / 1.73m 2 and signs to suggest rapid progression .
10 . Which are the top THREE causes of death in patients with hypertension and CKD ? a Sepsis . b CVD . c Heart failure . d Sudden cardiac death .
‘ normal kidney function ’ ( although no urinalysis was undertaken at the time ). A repeat test confirms he now has CKD .
The GP aims to get better control of his blood pressure , adding in a calcium-channel blocker . His blood pressure remains at around 140mmHg each time he sees the GP . The GP suggests he undertakes home blood pressure monitoring , which reveals his blood pressure is often much higher , with no nocturnal dipping . Lowering his cardiovascular risk and protecting his residual kidney function are now the treatment priority .
CONCLUSION
IN Australian general practice , many patients have high blood pressure . In addition to monitoring and managing their blood pressure through diet and medication , it is also important to evaluate and mitigate their risks of organ damage , beyond simply better blood pressure control . Just as cardiovascular risk should be estimated and treated when identified , all people with high blood pressure should be evaluated for CKD from the time of their diagnosis . Once identified , CKD requires specific investigations to exclude treatable causes of kidney damage alongside multifactorial therapy to slow the decline in kidney function .
RESOURCES
• Kidney Disease Improving Global Outcomes ( KDIGO ) — CKD evaluation and management bit . ly / 4cUvH75
• KDIGO — Blood pressure in CKD bit . ly / 3WAlbMx
• UK National Institute for Health and Care Excellence ( NICE ) — CKD : assessment and management bit . ly / 4cRMYOn
• NICE — CKD in adults bit . ly / 3ynPcWy
• Kidney Health Australia — CKD management in primary care handbook bit . ly / 3LEf0kr
• NPS MedicineWise — CKD : Integrating kidney health into patient care bit . ly / 3Spk7ZE
• NHS — Investigation and management of CKD in adults in primary care bit . ly / 3SlLUKv
• National Kidney Foundation — High blood pressure and CKD bit . ly / 4cSosfT
References Available on request from howtotreat @ adg . com . au