michigan hypertension core curriculum - State of Michigan

than other groups. Similarly, Wong et al. demonstrated that patients with CKD, along with other CV
co-morbidities had poor control rates, despite higher rates of treatment than the general population. 12
This apparent paradox of more intensive treatment not leading to greater control highlights the
population often affected by CKD. CKD has been proven to confer resistance to the BP lowering effect
of antihypertensive agents. Large numbers of CKD patients come from underserved populations
and populations with limited economic resources and access to quality health care. As practitioners
approach the patient with CKD, recognition of the CV risk and the overall poor control should be
prominent in care considerations.
As noted more thoroughly elsewhere in this book, individuals presenting with HTN should
be screened for secondary and reversible causes. With relatively simple, inexpensive testing,
unrecognized CKD can be diagnosed and appropriate treatments prescribed. The work up should
include renal ultrasound to define kidney sizes, character and blood flow, urine dipstick and microscopy
along with a spot determination of urinary albumin/creatinine ratio or protein/creatinine ratio and
assessment of renal function and serum glucose. In addition, providers need to be aware that there
are not only differences in prevalence of disease among race and gender groups, but also differences
in rates of HTN control that may affect outcomes. 13-17 Providers must also prepare themselves to follow
up and re-evaluate patients as often as is necessary to ensure good outcomes.
Although the development of CKD can seem complicated, the treatment is often relatively
straightforward. First and foremost, BP must be controlled. There is a clear relationship between
increasing blood pressures and CV death. 18 In addition, increasing BP clearly contributes to
progressive declines in renal function. 19 Practitioners should adhere to recommendations from the Joint
National Committee on Hypertension (JNC-7). 20 Important for outcome is an appreciation that close
to target is not on-target and that we maintain therapeutic inertia towards achieving good HTN control.
The cornerstone of drug therapy for CKD are the ACE-I (and increasingly ARB’s). 21,22 Angiotensin
converting enzyme inhibitors have been shown to improve blood pressure, slow progression of CKD
and reduce proteinuria. 23-25 There is an increasing literature supporting ARB use, particularly in those
with type 2 DM. 26,27 In addition, diuretic therapy and dietary sodium reduction should be standard in
the approach to treatment of HTN in CKD. As CKD affected individuals will often have multiple co-
morbidities (HTN, DM, obesity, hyperlipidemia), a holistic approach involving coordination of providers
will be necessary to achieve optimal results.
NKFM & MDCH 43