Some doctors say that hypertension and kidney disease can be “incompatible”? How to understand this statement, in fact, hypertension and kidney disease are the cause of each other, and also the aggravating factor of each. Once it occurs, according to the doctor’s advice, active treatment, choose the right antihypertensive drugs, to control blood pressure at a reasonable level.
1, the relationship between hypertension and kidney disease: mutual etiology and aggravating factors
Hypertension can lead to lesions in several organs and systems throughout the body, of which the kidney is an important target organ of damage.
The main manifestation is renal vasculopathy, called benign renal small arteriosclerosis, which is seen in the late stage of glomerular atrophy and sclerosis, and eventually leads to complete loss of renal function.
The impaired renal function can also lead to further increase in blood pressure due to impaired renal excretion of water and sodium, increased vascular endothelial damage factors, and activation of the renin-angiotensin-aldosterone system.
Some data show that 63% to 90% of patients with malignant hypertension have varying degrees of renal structural and functional damage, and can rapidly progress to end-stage renal disease.
2, chronic kidney disease patients, how much blood pressure control is better? And how to treat with medication?
(1) The goal of blood pressure reduction should be clear
Chronic kidney disease (CKD) combined with hypertension patients with systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg when the start of drug antihypertensive treatment.
The target goal of antihypertensive therapy is <140/90mmHg when albuminuria is <30mg/d, and <130/80mmHg when albuminuria is 30-300mg/d or higher, and the antihypertensive goal can be relaxed in patients over 60 years old.
(2) How to treat chronic kidney disease with hypertension with medication?
In patients with chronic kidney disease (CKD) combined with hypertension, angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor antagonists (ARB), calcium channel blockers (CCB), alpha-blockers, beta-blockers, and diuretics can be chosen as initial medications.
– Angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor antagonists (ARB) not only have antihypertensive effects, but also reduce proteinuria, delay decompensation of renal function, and improve renal prognosis in patients with chronic kidney disease (CKD). Initial antihypertensive therapy should include an ACEI (e.g., captopril, benazepril) or ARB (e.g., valsartan, losartan), alone or in combination with other antihypertensive drugs, but the combination of both drugs is not recommended. It can still be used with caution when the blood creatinine is elevated <30% from the basal value after medication, and can be considered for dose reduction or discontinuation when it exceeds 30%.
– Both dihydropyridines and non-dihydropyridines calcium channel blockers (CCB) can be applied, and their renal protective capacity depends mainly on their antihypertensive effect. In patients with glomerular filtration rate (GFR) >30mI/(min-1.73m2) (CKD stage 1~3), thiazide diuretics are effective, such as hydrochlorothiazide; in patients with GFR <30mI/(min-1.73m2) (CKD stage 4~5), tab diuretics, such as furosemide, are available. Diuretics should be used at low doses. Excessive diuresis can lead to hypovolemia and hypotension or decreased glomerular filtration rate (GFR). Aldosterone antagonists in combination with ACEI or ARB may accelerate the deterioration of renal function and the risk of hyperkalemia.
– Beta-blockers can counteract the excessive activation of sympathetic nervous system and exert antihypertensive effects. α and β-blockers have better advantages to exert cardioprotective effects and can be applied in the antihypertensive treatment of patients with chronic kidney disease (CKD) in different periods. Other antihypertensive drugs, such as α1 receptor blockers and central α agonists, can be used in combination with other antihypertensive drugs as appropriate.
(3) What is the best blood pressure control for end-stage renal disease dialysis patients?
Some patients exhibit refractory hypertension and require multiple antihypertensive drugs in combination.
The use of RAS inhibitors in hemodialysis patients should be monitored for potassium and creatinine levels. The use of antihypertensive drugs in the phase of sudden reduction of dialysis blood volume should be avoided to avoid severe hypotension.
The dose of antihypertensive drugs needs to be adjusted taking into account the hemodynamic changes and the clearance of the drugs by dialysis.
Blood pressure measured before dialysis or in the office does not reflect well the average blood pressure of dialysis patients, and home blood pressure measurement is recommended for patients. Blood pressure variability in dialysis patients should not be excessive, and the ideal target systolic blood pressure after dialysis is 120 to 140 mmHg.
References
[1]Wang Shuping,Liu Shujun,Li Qifeng,Wang Yande. Clinical and pathological analysis of patients with renal damage due to hypertension [J]. Chinese Experimental Diagnostics,2021,25(11):1683-1685.
[2]Dai L,Deng Junshu,Zheng Shijie,Zheng Youxiang,Liu Xiufeng,Jin Zhengang,Qian Guihua,Xiong Lijun,Wang Fujun,Editorial Board of this journal. What is the optimal BP target value for patients with hypertension combined with chronic kidney disease? [J]. Chinese Journal of Hypertension,2012,20(05):407-410.
[3] Revision Committee of the Chinese Guidelines for the Prevention and Treatment of Hypertension. Chinese guidelines for the prevention and treatment of hypertension (2018 revised edition) [J]. Chinese Journal of Cardiovascular Diseases,2019,24(1):45-46.