Current Controversies over the Management of Elderly Hypertension with Impaired Renal Function

Moon–Jae Kim

doi:10.5646/jksh.2011.17.4.148

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Kim: Current Controversies over the Management of Elderly Hypertension with Impaired Renal Function

Review

J Korean Soc Hypertens 2011;17(4):148-155.

Published online: 10 December 2011

DOI: https://doi.org/10.5646/jksh.2011.17.4.148

Current Controversies over the Management of Elderly Hypertension with Impaired Renal Function

Moon–Jae Kim, MD

Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea

Tel: 032) 890–2538, Fax: 032) 882–6578 E-mail: nhkimj@inha.ac.kr

Received 29 November 201112 December 2011 Accepted 12 December 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Both hypertension and aging impact renal function. Elderly patients are more likely to have chronic kidney disease (CKD), usually defined by estimated glomerular filtration rate 60 mL/min/1.73 m². Multiple studies over the past two decades have shown that CKD is a powerful cardiovascular disease (CVD) risk factor. Reduced kidney function in elderly people is a marker for adverse outcomes. The major goals of lowering blood pressure (BP) in patients with CKD include reduction of mortality, CVD events and slowing progression. Main considerations in the management of hypertension include selection of a target BP and selection of agents used to attain the chosen target. Current clinical practice guidelines for BP targets and choice of anti–hypertensive agents in elderly patients with CKD are not specific. Older patients with CKD might experience increased mortality and hospitalizations in association with lower baseline BP values. This review outlines controversies in applying current guidelines for the management of BP to older patients with CKD. Because of the high burden of other comorbidities in older patients with CKD, strict adherence to guidelines for the management of hypertension may not always represent the most adequate approach.

Keywords: Elderly hypertension, Chronic kidney disease, Blood pressure target

References

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Table 1.

NKF K/DOQI 2002. Classification of the severity of CKD

Stage	Description	eGFR mL/min/1.73m²	Typical Scr	Consequences	Actions required
0	Patients↑at - risk	＞90 with risk factors	N	None	Screening risk reduction
1	Kidney damage with normal or ↑ GFR	＞90	N	None	Diagnosis and treatment of comorbid conditions, slow progression of CKD risk
2	Kidney damage with mild ↓ GFR	60–89	1.5–2	Hypertension 2° HPTH	Treatment hypertension (＜130/80 mm Hg), estimate progression, start PO₄ restriction
3	Moderate ↓ GFR	30–59	2–4	Hypertension 2° HPTH anemia	Restrict Na & K modest protein restriction, evaluation & treatment complications
4	Severe ↓ GFR	15–29	5–8	Above plus salt & water retention	Prepare for RRT
5	ESRD	＜10–14	＞10	Above plus pulm edema ↑ K acidosis	Start of RRT to sustain life

NKF, National Kidney Foundation; K/DOQI, Kidney Disease Outcomes Quality Initiative; CKD, chronic kidney disease; GFR, glomerular filtration rate; Scr, serum creatinine; N, normal; ESRD, end–stage renal disease; HPTH, hyperparathyroidism; PO₄, phosphate; RRT, renal replacement therapy.

Table 2.

Published guidelines on BP targets in patients with non–dialysis CKD (stages 1–4)

Guideline agency	Country	Year	Tagert recommendation(mmHg)	Agent(s) recommended
Hypertension Society Guidelines including recommendations for CKD
JNC 7	United States	2003	＜130/80	ACEI or ARB (diabetic kidney disease or nondiabetic kidney disease)
ESH/ESC	Europe	2007	＜130/80	ACEI or ARB (diabetic kidney disease or nondiabetic kidney disease)
BHC–IV	United Kingdom	2004	＜130/80 ＜125/75 in the presence of proteinuria ≥1g/24hr	ACEI (nondiabetic kidney disease) ARB (diabetic kidney disease, type2 diabetes) ACEI or ARB (diabetic kidney disease, type 1 diabetes)
Renal Society Guidelines
NKF/KDOQI	United States	2004	＜130/80 ＜125/75 (in the presence of proteinuria ＞1g/24hr)	ACEI or ARB (diabetic kidney disease or nondiabetic kindey disease with proteinuria)
EBPG	Europe	EBPG Endorsed the 2004 NKF/DOQI	See NKF/KDOQI guidelines	See NKF/KDOQI guidelines
CSN	Canada	2008	＜130/80	ACEI or ARB (diabetic kidney disease) ACEI, ARB, thiazide diuretic, ß–blocker (patients aged 60 yr or younger)
BRA	United Kingdom	2010, 2011	＜140/90 (no significant proteinuria) ＜130/80 (proteinuria of diabetes)	ACEI or ARB (diabetic kindey disease or nondiabetic kidney disease with proteinuria ＞0.5 g/day

BP, blood pressure; CKD, chronic kidney disease; JNC 7, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; ACEI, angiotensin–converting enzyme inhibitor; ARB, angiotensin receptor blocker; ESH/ESC, European Society of Hyper–tension/European Society of Cardiology; BHC–IV, British Hypertension Society; NKF/KDOQI, National Kidney Foundation Disease Outcomes Quality Initiative; EBPG, European Best Practice Guideline; CSN, Canadian Society of Nephrology; BRA, British Renal Association.

Table 3.

Trials examining the effect of blood pressure lowering on progression of CKD

	Target BP	Results	Subgroup analysis A	Age (yr)	Mean age (yr)
Diabetes
Estacio et al.²²⁾	DBP ＜75 vs. 80–89	No difference in progression		40–74	59.5
UKPDS²³⁾	＜150/85 vs. ＜180/105	No difference in progression	Reduced risk ofmicroalbuminuria at 6 yr	25–65	56.0
Non diabetes
Wright et al.²⁴⁾	MAP 102–107 vs. ≤92 (125/75)	No difference in progression	Trend toward greaterbenefit in patients with proteinuria	18–70	54.6
Klahr et al.²⁵⁾	MAP ≤107 vs. ＜92	No difference in Progression	Secondary analysis showed greater benefit in patients with greater degrees of proteinuria	18–70	52.0

The MDRD study had different blood pressure targets based on age and required a MAP 107 (equivalent to 140/90) for patients 18 to 60 years of age and MAP 113 for patients 61 years of age (equivalent to 160/90).

CKD, chronic kidney disease; BP, blood pressure; DBP, diastolic blood pressure; MAP, mean arterial pressure; MDRD, Modification of Diet in Renal Disease.

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