michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
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development <strong>of</strong> essential HTN can set in motion a self-perpetuating cycle <strong>of</strong> damage. Hypertension<br />
causes kidney injury, which exacerbates HTN, causing further kidney injury. Of note, not all CKD<br />
attributed to HTN is initially cause by HTN. There are likely many individuals, particularly young people<br />
who develop unrecognized, self-limited glomerular disease that results in kidney injury and HTN. For<br />
these individuals with asymptomatic initial kidney injury, by the time they present for medical care will<br />
have HTN, abnormal kidney function and normal serologic markers. As such, these individuals tend to<br />
be characterized as having CKD caused by HTN rather than HTN caused by CKD.<br />
There are a number <strong>of</strong> additional causes <strong>of</strong> CKD that are worth discussing because although<br />
they are not preventable, early detection and treatment can significantly reduce the morbidity<br />
associated with such diseases. Autosomal dominant polycystic kidney disease (ADPKD) affects 1<br />
in 500 (approximately 600,000 in the U.S.) and contributes to approximately 10% <strong>of</strong> advanced CKD<br />
cases. Polycystic kidney disease individuals develop HTN from the same mechanisms as described<br />
above. In addition, HTN may be further exacerbated by the fact that ADPKD individuals with advanced<br />
CKD tend to have less anemia than non-ADPKD individuals. People affected with ADPKD may<br />
also have HTN from essential HTN or obesity, just like the general population. There are additional<br />
causes <strong>of</strong> CKD (Table 1) that can directly or indirectly contribute to HTN that should be kept in mind in<br />
assessing individuals with HTN.<br />
Chronic kidney disease is important not just because <strong>of</strong> the risk for HTN and ESRD, but<br />
also because <strong>of</strong> the increased risk for cardiovascular (CV) events. 5-7 Individuals with CKD have a<br />
significantly increased risk for CV mortality, starting with relatively small decrements in overall renal<br />
function. 8-10 Hypertension accelerates and further exacerbates this situation. As expected, in the<br />
individual who has the not uncommon combination <strong>of</strong> CKD, HTN and DM is at extraordinarily high risk<br />
<strong>of</strong> CV death. Treatment <strong>of</strong> individuals with CKD is essential to effect what are certainly preventable<br />
excess deaths in this population. Numerous studies demonstrate that control <strong>of</strong> blood pressure can<br />
slow progression <strong>of</strong> CKD, particularly in patients with significant proteinuria at the onset <strong>of</strong> therapy.<br />
Further, and perhaps more importantly, HTN and CKD control can decrease CV events and death.<br />
An analysis <strong>of</strong> the Fourth National Health and Nutrition Examination Survey (NHANES IV)<br />
reveals that only 37% <strong>of</strong> subjects had blood pressures controlled to a goal <strong>of</strong> < 130/< 80 mmHg. 11<br />
The major issue was inadequate control <strong>of</strong> systolic blood pressures. African Americans were more<br />
than twice as likely and the elderly almost five times more likely to have uncontrolled blood pressures<br />
42 Hypertension Core Curriculum