How To Choose The Correct Size Of Suction Catheter

Treatment of Hypertension in CKD patients

 

Illustrative case

A 56-year M CKD patient was admitted with breathlessness due for hemodialysis. He was a known DM, HTN on Tab Amlodipine 10 mg PO BD. Blood pressure was unusually high since morning on the day of admission. Choice and timing of an add on antihypertensive was to be decided. 

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Hypertension is both the cause and effect of CKD. Controlling hypertension reduces cardiovascular morbidity and progression of CKD. Decline in GFR increases sympathetic tone and activates the Renin Angiotensin Aldosterone (RAAS) System.

 

Proteinuria is both a marker of CKD and can be used for the progression of CKD over time

Albumin to creatinine ratio > 3 mg/ mmol in spot urine is easier to test and more reliable over 24-hour proteinuria. The presence of proteinuria effects the choice of antihypertensive medicines.

 

Albumin > 300 mg per 24-hour urine collection is the standard 

 

Albumin > 1 gm per 24-hour urine collection is indicative of gross perineuria.

Blood pressure control reduces proteinuria and is also Reno protective.

 

Goals of blood pressure control

Generally, a target systolic blood pressure < 140 mm HG to 130 mm Hg is considered adequate.

 

Pharmacological treatment

RAAS System Blockage  

First line therapy for proteinuric CKD with hypertension – these agents reduce proteinuria independent of antihypertensive effect

ACEI or ± ARB combination is not recommended in CKD

 

Diuretics are chosen for non-proteinuric hypertension

Avoid if proteinuria is present  

Thiazides

Loop Diuretics

Potassium sparing diuretics – risk of hyperkalemia – can use with monitoring

 

Calcium channel Blockers

First line therapy for non proteinuric CKD

Addition of CCB to RAAS blocker improve BP control without worsening proteinuria

Sometimes causes peripheral edema similar to CKD

 

B Blockers

Use of B blockers are both reno protective and have survival benefits. Generally preferred for dialysis dependent patients

Carvedilol is hepatically excreted and has additional vasodilatory properties

 

Alpha blockers

Add on therapy but not first line

Prazosin

Terazosin

Doxazosin

 

Central Sympatholytic

Clonidine

Generally, the last choice due to its withdrawal hypertension and development of tolerance.

 

Evening dose/ Chronotherapy

In CKD elevated nighttime blood pressure is associated with poor outcome. Therefore, one antihypertensive medication should be dosed in the evening/ bedtime.

 

Post Renal Transplant

RAAS agents are avoided

Dihydropyridine CCB confer benefit by vasodilation of the afferent arterioles.

Tacrolimus causes vasoconstriction of the afferent arterioles.      

 

Management of hypertension in respect of Dialysis

·        Studies support choice of any B- Blocker for controlling Hypertension in ongoing dialysis patient not improved with ultrafiltration. This is due to dysregulated sympathetic system in such patients.

 

·        Intradialytic hypotension is a well-known phenomenon. It is generally agreed that if a patient is on antihypertensive therapy and the blood pressure on other days is systolic < 130 -140 on medicines then on the day of dialysis s/he should not take Blood Pressure medicine to safeguard against intradialytic hypotension. Antihypertensive medicines can be given during or after HD in stable condition on an adjusted dose. Any episode of hypotension will be detrimental to the survival and long-term prognosis. Pre dialysis blood systolic pressure < 120 mmHg has been shown to have poor 30-day outcome in critically ill. Lowest mortality is seen in pre-dialysis systolic blood pressure of 160-180.     

 

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Dr. Prashant Kumar