Hypertension in CKD,Michael J Casey, MD Wake Nephrology Associates,Hypertension Stats,HTN affects approximately 1 billion worldwide $500 billion in direct costs Continuous, consistent and independent relationship between BP and Cads For those age 40-70, each increased increment of 20/10 mmHg in BP doubles the risk of CVD across the entire BP range of 115/75 to 185/115. Only 35% of hypertensive patients on treatment are under control.,Hypertension as Defined by JNC VII,120/80 - normal; “optimal” 121-139/80-89 - “pre-hypertension” Controversial More a health policy statement 140-160/90-100 - Stage 1 Hypertension 160/100 - Stage 2 Hypertension,Evaluation of the Hypertensive Pt,Age and rapidity of HBP onset Accurate measurement of BP Medication review Family History H/O CVD or kidney disease EtOH and tobacco Sleep history,Evaluation of the Hypertensive Pt,Evidence of Volume status Edema Heart & lung exam for CHF End Organ Damage Albuminuria/Proteinuria (MACR, 24 hr urine) LVH (ECG, Echo) CKD,Measurement of Blood Pressure,Seated position with arm supported ideal Allow patient to settle for several minutes Proper sized cuff Bladder to encircle 80 100% arm Bladder width 40-50% of arm Confirm 2 readings 5 minutes apart in both arms for initial diagnosis If taken in wrist or legs, the cuff must be at the level of the heart,BP Measurement,Home BP Monitoring,Self readings or continuous ambulatory monitoring Helpful adjunct to office readings More readings in patients usual environment Better correlated with cardiovascular outcomes Improves patient compliance Helps clarify symptoms Defines masked and white coat hypertension,Home BP Monitoring,Patients need to be taught proper methods No wrist cuffs Semi-automated electronic cuffs Cuff needs to be checked against office readings Frequency of monitoring can vary All current outcome data/guidelines/trails are from office readings,Ambulatory BP Monitoring,Ambulatory BP Monitoring,Ambulatory BP Monitoring,More reproducible than office measurements Helpful in early diagnosis Unexplained microalbuminuria or LVH White Coat Hypertension Resistant Hypertension No long term studies yet,Prevalence of HTN in CKD,Hypertension in CKD,80% of patients with CKD have HBP Most start with essential hypertension As GFR decreases it is more dependent on salt/water retention from decreased GFR CKD patients also have derangements in the Renin/Angiotensin/Aldosterone system,Treatment of Hypertension,Goal depends on disease state 130/80 if DM, CKD, CVDz 25mg Ineffective at GFR 50 Can boost efficacy of loop diuretics,