HYPERTENSION Kidney Diseases and Blood Pressure

Mohammad Ilyas, M.D.

Assistant Clinical Professor

University of Florida / Health Sciences Center

Jacksonville, Florida USA

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7/2/2014

Outline

1. Definition, Regulation and Pathophysiology

2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory

Blood Pressure Monitoring

3. Evaluation of Primary Versus Secondary

4. Sequel of Hypertension and Hypertension Emergencies

5. Management of Hypertension (Non-Pharmacology versus Drug Therapy)

6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep

Disorders.

7. Hypertension in Renal diseases and Pregnancies

8. Pediatric, Neonatal and Genetic Hypertension

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Kidney and blood pressure

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Kidney Diseases and Blood Pressure

Definition and epidemiology

Prevalence of HTN with CKD

Pathogenesis

Risk factors for progression

Therapy of HTN with CKD

HTN with ESRD

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What proportion of adult population

has CKD ?

1. One in four

2. One in eight

3. One in ten

4. One in twenty

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What proportion of adult population

has CKD ?

1. One in four

2. One in eight

3. One in ten

4. One in twenty

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INTRODUCTION

CKD = GFR < 60 mL/min/m2

24.5 % of 60 years and older

has CKD -2006.

13.1% (1/8) of adult USA

population has CKD

27 Millions

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How does high blood pressure affect the kidneys?

• High blood pressure can damage blood vessels

by causing scaring and weaken the vessel wall.

• It decrease the GFR fluid retention

hypertension renal damage

• 2nd leading cause of renal failure

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Causes of kidney failure in the United

States

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Stages of CKD

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Stage GFR* Description

1 90+ Normal kidney function but urine findings or

structural abnormalities or genetic trait point to

kidney disease

2 60-89 Mildly reduced kidney function, and other

findings (as for stage 1) point to kidney disease

3A 3B

45-59 30-44

Moderately reduced kidney function

4 15-29 Severely reduced kidney function

5 <15 or on

dialysis

Very severe, or end stage kidney failure

The primary cause of death in CKD is?

A. Infection

B. Cardio Vascular Disease

C. Kidney failure

D. Malignancies

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The primary cause of death in CKD is?

A. Infection

B. Cardio Vascular Disease

C. Kidney failure

D. Malignancies

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Why CKD Patient have CVD?

30-50% INFLAMATION (increased CRP, increase IL-6,

decrease albumin)

CRP is a marker for CVD

CKD have metastatic calcification (increase PTHi,

Ca, PO4 level)

Hyperlipidemia

Hypertension

Anemia

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Hypertension in CKD

23.3% of individuals without CKD, and

35.8% of stage 1,

48.1% of stage 2,

59.9% of stage 3, and

84.1% of stage 4-5 CKD patients

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PATHOGENESIS

The pathogenesis of hypertension varies with the

type of disease

Glomerular versus Vascular

&

Acute versus Chronic

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Acute glomerular disease

Acute glomerular disease, (e.g.

poststreptococcal glomerulonephritis)

Increase Blood pressure is primarily due to fluid

overload (as evidenced by suppression of the RAAS

and enhanced release of atrial natriuretic peptide)

Fluid overload is due to Na retention, Na+ retention is

due to increased reabsorption in the collecting

tubules.

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Acute glomerular disease

Two different abnormalities in collecting tubule

function have been identified in glomerular disease,

both of which could increase sodium reabsorption:

Relative resistance to Atrial Natriuretic Peptide, (ANP)

due at least in part to more rapid degradation of the

second messenger cyclic GMP by the enzyme

phosphodiesterase .

Increased activity of the Na-K-ATPase pump in the

cortical collecting tubule but not other nephron

segments . This pump provides the energy for active

sodium transport by pumping reabsorbed sodium out

the cell into the peritubular capillary.

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Acute vascular disease

Hypertension is also common in acute vascular diseases,

such as vasculitis or scleroderma renal crisis.

In these settings, the elevation in blood pressure results

from ischemia-induced activation of the renin-

angiotensin system rather than volume expansion

This difference in mechanism between glomerular and

vascular disease may be of therapeutic importance

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PATHOGENESIS

1. Sodium and volume excess due to diminished

sodium excretory capacity.

2. Activation of the renin-angiotensin-aldosterone

system due to primary vascular disease or to

regional ischemia induced by scarring.

3. Increased activity of the sympathetic nervous

system.

4. An increase in endothelium-derived

vasoconstrictors (such as endothelin) 7/2/2014

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PATHOGENESIS

5. A reduction in endothelium-derived

vasodilators (such as nitric oxide).

6. The administration of erythropoietin (EPO).

7. An increase in intracellular calcium induced by

PTH excess.

8. Calcification of the arterial tree.

9. Preexistent primary hypertension.

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Angiotensin and CKD

Angiotensin, which is a protein, is a component of

the renin-angiotensin-aldosterone system (RAAS),

which performs important functions in the

regulation of fluid balance and blood pressure in

the human body.

It has two forms:

Angiotensin I (AI) and Angiotensin II (AG II).

Generally, the function of angiotensin is to raise

the blood pressure. 7/2/2014

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Addition to the factors

Patients with end-stage renal disease are more

likely to have an increase in central pulse

pressure and isolated systolic hypertension.

Patients with chronic kidney disease may not

demonstrate the normal nocturnal decline in

blood pressure (such patients are called

"nondippers"),

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TREATMENT OF HTN IN CKD

Treatment of even mild hypertension is

important in patients with chronic kidney

disease (CKD) to protect against both

1. Progressive renal function loss and

2. Cardiovascular disease, the incidence of

which is increased with mild to moderate

CKD

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Goal of BP when treating a patient

with proteinuria is?

A.< 160/100

B.< 140/90

C.< 130/80

D.< 115/70

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Goal of BP when treating a patient

with proteinuria is?

A.< 160/100

B.< 140/90

C.< 130/80

D.< 115/70

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Goal blood pressure

Management of blood pressure in chronic kidney

disease that goal blood pressure depends upon the

degree of proteinuria:

Proteinuric CKD, (500 mg/day or higher),

the BP < 130/80 mmHg.

Nonproteinuric CKD, (<500 mg/day),

the BP < 140/90 mmHg.

Isolated systolic HTN, systolic pressure <150 mmHg

Proteinuria goal of less than 1000 mg/day

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BP measurement in CKD

24-hour ambulatory blood pressure is a stronger

predictor of end-stage renal disease (ESRD),

cardiovascular disease, and death than office-based

measurements

A daytime ambulatory systolic pressure greater than 145

mmHg was associated with a threefold increased risk of

developing cardiovascular disease and a nearly twofold

increased risk of ESRD or death compared with patients

whose daytime systolic pressure was 126 to 135 mmHg.

The prognostic value of nighttime ambulatory blood

pressure was even stronger

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Management

1. Sodium restriction

2. Diuretics

1. Thiazide diuretics become less effective when the GFR is less than 30

mL/min

2. Loop diuretics are preferred as initial therapy

3. Antihypertensive therapy in proteinuric CKD

1. angiotensin inhibitors as first-line therapy

2. CCB and diuretic with ACE or ARB

4. Antihypertensive therapy in non-proteinuric CKD

1. with edema, initial therapy with a loop diuretic

2. without edema, an ACE, and then add a dihydropyridine CCB

5. Benefit from nocturnal therapy 7/2/2014

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Hypertension in ESRD

There are several major issues to consider when

approaching hypertension in dialysis patients

1.What is the pathogenesis of the elevation in

blood pressure (BP)?

2.How is hypertension best defined?

3.What are the target BP goals?

4.How should the hypertension be treated?

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Hypertension and ESRD

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Hypertension in ESRD

Over 50 to 60 percent of hemodialysis

Nearly 30 percent of peritoneal dialysis patients are

hypertensive

Volume overload

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Quiz Test your knowledge

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Quiz 1. Goal of BP when treating a

patient with proteinuria is?

A.< 160/100

B.< 140/90

C.< 130/80

D.< 115/70

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Quiz 1. Goal of BP when treating a

patient with proteinuria is?

A.< 160/100

B.< 140/90

C.< 130/80

D.< 115/70

7/2/2014

36

Quiz 2. What proportion of adult

population has CKD ?

1. One in four

2. One in eight

3. One in ten

4. One in twenty

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Quiz 2. What proportion of adult

population has CKD ?

1. One in four

2. One in eight

3. One in ten

4. One in twenty

7/2/2014

38

Quiz 3. The primary cause of death in

CKD is?

A. Infection

B. Cardio Vascular Disease

C. Kidney failure

D. Malignancies

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Quiz 3. The primary cause of death in

CKD is?

A. Infection

B. Cardio Vascular Disease

C. Kidney failure

D. Malignancies

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Quiz 4. The pathogenesis of hypertension in

glomerular disease includes all EXCEPT?

A. Increase Blood pressure is primarily due to fluid

overload.

B. Fluid overload is due to Na retention

C. Relative resistance to atrial natriuretic peptide

D. Increased activity of the Na-K-ATPase pump

E. Blood pressure results from ischemia-induced activation

of the renin-angiotensin system

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Quiz 4. The pathogenesis of hypertension in

glomerular disease includes all EXCEPT?

A. Increase Blood pressure is primarily due to fluid

overload.

B. Fluid overload is due to Na retention

C. Relative resistance to atrial natriuretic peptide

D. Increased activity of the Na-K-ATPase pump

E. Blood pressure results from ischemia-induced activation

of the renin-angiotensin system

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