[KIDNEY] Hypertension Management (3.4)

[KIDNEY] Hypertension Management (3.4)

November 7, 2019 0 By Jose Scott


For clinical evaluation, management of risk factors for chronic kidney disease is in the center of the ambulatory care for older people with chronic kidney disease. One of the key factors impacting the progression of CKD and functionality of older people is blood pressure. Professor Alexander Rosenkranz the head of the department of Nephrology at Medical University of Graz will explain to us how to consider the pressure values depending on age and how to treat high blood pressure in older patients with chronic kidney disease. Most patients older than 65 years suffer from systolic hypertension which is mainly a consequence of material stiffness associated with aging. It is noteworthy for clinical practice that all the subjects tend to present with more changing and variety blood pressure values indicating that measurements in offic are reflecting real life values with less accuracy. It is necessary to ask all the patients to perform validated self measurements at home and then to report back to the office or to the community nurse. It could be demonstrated that so-called fit elderly that means patients between 65 and 80 years old profit from antihypertensive treatment in terms of organ protection and prevention of secondary morbidity such as chronic kidney disease in a way comparable to younger patients. Seen from absolute risk reduction to prevent secondary events all the patients even profit to a large extent than do younger ones. As the numbers needed to treat to prevent secondary organ damages is lower. In the recently performed SPRINT study more than 2,600 patients older than 75 years of age were included. Patients who were randomized to a treatment goal of systolic blood pressure of less than 120mm mercury exhibited a risk reduction of the combined endpoint of cardiovascular events of more than 30 percent compared to the standard treatment group. However one of the major drawbacks of this trial were the methods used to measure blood pressure which may result in too low values. Furthermore the cohort recruited to the SPRINT study will not be compared to older real-life patients in office for the multi mobility pattern and functionality. In SPRINT Diabetics, patients following cerebrovascular events and patient with cardiac insufficiency were excluded. In these groups the number of adverse events is expected to be much higher. Furthermore orthostatic hypotension, orthostatic dysregulation, was an exclusion criterium for participation in SPRINT. It’s therefore essential to interpret results of blood pressure aligned with multimobility subjective well-being and functionality as well as individual therapeutic goals expressed by patients during history taking. Also side effects of drugs used to lower blood pressure impact target setting in older patients. This includes orthostatic dysregulation, dizziness and especially tendency to fall and also a decline in kidney function. So in patients with a reduction of the glomerular filtration rate of more than 30% as inhibitors or angiotensin receptor blockers have to be reduced. If kidney function is just minimally reduced, less than 20% of initially measured GFR those regiments may be continued. It is important to recognize intermediate hypertensive blood pressure values not below 130 to 140 mm mercury systolic and 60 to 80 mm mercury diastolic medicine office. Choice of drugs to lower blood pressure in older subjects strongly depends on the co-morbidity patterns in functionality. Those points are in line with the newest guidance from the European Society of Cardiology and hypertension. Blood pressure targets are based on the age. In patients older than 65 years of age a blood pressure target of 130 to 140 systolic and 70 to 80 mm mercury diastolic has been recommended. This is a little bit higher than in younger patients. But everything is based on the functionality of the patients and if the patient can tolerate this therapy.