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