Resistant Hypertension in People With CKD: A Review

Kevin S Fay, Debbie L Cohen
American Journal of Kidney Diseases: the Official Journal of the National Kidney Foundation 2020 July 23
Resistant hypertension is common in the chronic kidney disease population and conveys increased risk for adverse cardiovascular outcomes and the development of end-stage kidney disease. Recently, the American College of Cardiology and the American Heart Association published a revised scientific statement on the definition and management of resistant hypertension, which codified the long-debated differences between pseudoresistant hypertension and true resistant hypertension. We review this distinction and its importance to nephrologists, who frequently encounter patients that fail antihypertensive therapy due to difficulty adhering to complex, multi-drug regimens. Second, we discuss the evaluation of patients with resistant hypertension, including appropriate screening and diagnostic testing for causes of secondary hypertension. Third, we examine the management of established resistant hypertension including medication optimization, recent clinical trials supporting lifestyle modifications, and the evidence behind the routine use of mineralocorticoid receptor antagonists. Special attention is given to the vital role of diuretics in the treatment of patients with chronic kidney disease. We propose an algorithm for the diagnosis and management of these cases. Finally, we briefly discuss the current state of antihypertensive device therapies including kidney denervation and baroreceptor-directed therapies.

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