Presentation on theme: "Malaysian Society of Nephrology Ministry of Health Malaysia Hypertension In Chronic Kidney Disease."— Presentation transcript:
Malaysian Society of Nephrology Ministry of Health Malaysia Hypertension In Chronic Kidney Disease
Renal disease loss of nephrons Systemic hypertension ProteinuriaProgressive decline in GFR Introduction
RENAL INJURY Nephron mass Glomerular capillary hypertension Glomerular permeability to macromolecules Filtration of plasma proteins Filtration of plasma proteins Proteinuria Excessive tubular protein reabsorbtion Tubulo-interstitial inflammation RENAL SCARRING SYSTEMIC HYPERTENSION CKD: Common pathway in disease progression
Therapeutic intervention inhibiting this common pathway may succeed in slowing the rate of progression of CRF irrespective of the initiating cause CKD: Common pathway in disease progression
Relative risk of ESRD according to quintile BP MRFIT study N= 332,544 men How important is systemic blood pressure control?
Treatment goal for hypertension in the general population has remained relatively the same for the last decade. GuidelinesBP target British Hypertension Society (2004)< 140/85 Malaysian Hypertension Society<140/90 JNC VII (2003)<140/90 What should be the treatment goal?
Should be lower than the general population Should be tailored according to : What should be the treatment goal for renal disease? the severity of renal failure the severity of the proteinuria
Aggressive BP control to 125/75 mmHg showed better preservation of GFR for those with proteinuria >3g/day. No additional benefit if proteinuria is < 1g/day Klahr S, Levey AS: NEJM 1994; 330:877 Proteinuria and target BP control
GuidelinesTarget BP British Hypertension Society (2004)<130/80 Malaysian Hypertension Society<130/80 JNC VII (2003)<130/80 What should be the treatment goal for renal disease?
Treatment goal should depend on the severity of proteinuria Proteinuria (g/d)BP target (mm Hg) >1125/75 <1130/80 What should be the treatment goal for non diabetic renal disease?
There is indisputable evidence from animal, laboratory and clinical studies that proteinuria per se contributes to progressive renal injury Proteinuria
Proteinuria and renal disease progression REIN SUBSTUDY : Progression of renal disease according to severity of proteinuria
It is now clear that different classes of antihypertensive agents have different antiproteinuric capacity ACEI and ARB have been showed to exhibit the highest capacity to diminish protein excretion in urine Proteinuria and renal disease progression
REIN Study : KIDNEY SURVIVAL ACE Inhibitors In Nephropathy P=0.04
COOPERATE STUDY: Median urinary protein excretion ACEI, ARB and combination treatment in Nephropathy
ACEI, ARB and combination treatment in Nephropathy COOPERATE STUDY: proportion reaching endpoints
ACEI or ARB should be the first choice antihypertensive agent in patient with significant proteinuria. Choice of antihypertensive agent for non diabetic renal disease
Dose of ACEI or ARB should be titrated to achieve both target BP and the disappearance of proteinuria Choice of antihypertensive agent for non diabetic renal disease
If target blood pressure is not achieved and especially in the presence of persistent proteinuria, an ARB should be added. Choice of antihypertensive agent for non diabetic renal disease
Check Cr and K + within 7-14 days after starting treatment especially in the presence of renal impairment An acute rise in Cr of 30% should be tolerated if BP is adequately reduced (<140/90), hyperkalaemia is absent and the patient is euvolaemic If Cr continues to rise, or hyperkalaemia persist, stop drugs; assess for bilateral RAS Precautions when starting ACEI or ARB
Choice of combination antihypertensive agents depend on the existing comorbidity Choice of antihypertensive agent for non diabetic renal disease
DiureticB-blockerACE IARBCCBAldosterone antagonist Heart failure Post-myocardial infarction High coronary risk Diabetes Chronic Kidney Disease Recurrent stroke prevention Drug(s) for the compelling indication
Concomitant Disease DiureticsB-blockersACEICa channel blocker Alpha- blocker ARB DiabetesCarefulcarefulyes GoutNoYes Yes/no HyperlipidaemiaCareful Yesyes IHDYes yes Heart FailureYesCarefulYescarefulyes AsthmaYesNoYes yes PVDYesCarefulYes yes Renal ImpairmentYes CarefulYesyesCareful Renal A StenosisYes CarefulYesyescareful Elderly with no co morbid cond. yes Choice of Anti-Hypertensive drugs in patient with concomitant disease
Since studies have demonstrated that most hypertensive patients will require multiple drugs to achieve target BP, the argument about which one is superior has become almost irrelevant We must provide all of the drugs needed to achieve maximal protection with the fewest adverse effects Choice of antihypertensive agent for non diabetic renal disease