Refractory Hypertension and Kidney Failure

HomeHypertensionVol. 77, No. 1Refractory Hypertension and Kidney Failure Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBRefractory FailureFocusing on the Social Determinants of Health Rajiv Agarwal AgarwalRajiv Correspondence to: Agarwal, Division Nephrology, Department Medicine, Indiana University School Medicine Richard L. Roudebush Veterans Administration Medical Center, 1481 W 10th St, Indianapolis, IN. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8355-7100 Search for more papers by this author Originally published8 Dec 2020https://doi.org/10.1161/HYPERTENSIONAHA.120.15322Hypertension. 2021;77:82–84This article is a commentary followingAdverse Outcomes Associated With Refractory Treatment-Resistant in Chronic Renal Insufficiency CohortSee related article, pp 72–81The definition resistant hypertension well known standardized. However, refractory its epidemiology less understood. In 2012, patients followed specialty clinic, Alabama, Birmingham, were diagnosed with if blood pressure (BP) remained uncontrolled after ≥3 visits clinic within minimum 6-month follow-up period.1 retrospective study, only about 10% had hypertension. 2020, from same at was who needed ≥5 antihypertensive medications including chlorthalidone MRA (mineralocorticoid receptor antagonist) BP but without specification period.2 Nearly half thought have hypertension, either not taking their or controlled 24-hour ambulatory monitoring. Although, changed, investigators concluded that disease real rare.In issue Hypertension, Buhnerkempe et al3 report association increasing severity kidney failure cardiovascular outcomes chronic (CKD) participating CRIC (Chronic Cohort) study. At baseline, apparent treatment study present 136 (4.3%) patients, 1005 (31.9%) neither these conditions 2006 (63.7%) patients. Apparent defined received medications, diuretic, being ≥140/90 mm Hg. as Hg prescription drugs diuretic. Over period 10 years, compared those outcome estimated glomerular filtration rate decline ≥50% receipt dialysis 73% higher Using similar comparisons, stroke, myocardial infarction, heart hospitalization between year 6 10, 172% higher. As expected, associated an older age, body mass index, diabetes, failure, disease, atrial fibrillation. Also, urine albumin creatinine ratio lower seen These renin angiotensin aldosterone system inhibitors (82% 88% hypertension), 71% control group. Eight percent 9% mineralocorticoid antagonists respectively. What remarkable steep gradient social determinants health; often Black education.Need Standardize Definition HypertensionDespite American College Cardiology/American Heart Association 2017 guidelines,4 al used threshold office diagnose The thresholds seems reasonable because BPs measured using aneroid machine auscultation technician. newer guidelines recommend ≥130/80 use measurement technique oscillometric method absence observer room. differences 2 measurements average 12.7 Hg.5 But important, variability techniques such cannot be interchangeably. Thus, decision appears justified. Whether they should prior definitions Birmingham remains moot; few would qualified since MRAs. Nonetheless, hinders comparisons various studies.Apparent Versus True HypertensionIt important recognize results confirmed monitoring assessing adherence medications. By way example, Siddiqui al2 studied 54 attending least 5 MRA. Of 45 (83%) completed data drug based urinary metabolites available 40 (74%). diagnosis Association/American Cardiology (mean ≥125/75 mean awake ≥130/80). Fifteen no measurable medication urine, 40% fully adherent all prescribed rest partially adherent; 12.5% Therefore, ≈52.5% true Other studies nearly prevalence poor can attributed nonadherence.6Social health previously given much attention, especially population CKD, may causally genesis low education also literacy, access care, reduced lack supply medications7; may, therefore, provoke A recent global survey assess found level associate control.8 surveys associates household income.9 structural factors addressed management patients.Mineralocorticoid Receptor Antagonists HypertensionOf note, despite receiving having poorly European <45 mL/(min·1.73 m2) serum K ≥4.5 mEq/L. MRAs small. This might reflect problems hyperkalemia For instance, spironolactone 25 leads discontinuation spironolactone, due hyperkalemia, 34% over 12 weeks treatment.10 falls 14% oral potassium-binding administered. Furthermore, effective lowering substantially CKD enabled K-binding drugs. needs explored larger studies.Refractory ContinuumEarly suggests reflects overactivation sympathetic nervous system. overactivated most. unique condition whether highest risk state continuum will require further studies.In conclusion, uncommon. 4.3%. Excluding nonadherence white coat effect likely reduce 2% fact, randomly selected; random sampling 0.6%.9 elevated risk. How best managed unknown. Enabling agents K-losing diuretics strategies improve population. Addressing has been largely ignored intervention target. upstream interventions dietary sodium intake, fresh fruit vegetables, care potential rates which impact downstream events progression risk.Sources FundingR. supported National Institutes R01 HL126903-05 grant VA Merit Review I01CX001753-01A1.DisclosuresR. reports personal fees nonfinancial support Bayer Healthcare Pharmaceuticals, Akebia Therapeutics, Janssen, Relypsa, Vifor Pharma, Boeringher Ingelheim, Sanofi, Eli Lilly, AstraZeneca, Fresenius; he Ironwood Merck & Co, Lexicon Reata Otsuka America Pharmaceutical, Opko E. R. Squibb Sons; member steering committees randomized trials Bayer, Relypsa; adjudication Boehringer Janssen; served editor Journal Nephrology Dialysis Transplantation UpToDate; research grants US Health.FootnotesThe opinions expressed are necessarily Association.For Sources Funding Disclosures, see page 84.Correspondence protected]eduReferences1. 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Hypertension. 2021;77:72-81 January 2021Vol Issue 1Article InformationMetrics Download: 116 © 2020 Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.120.15322PMID: 33296245 publishedDecember 8, Keywordscardiovascular diseasechlorthalidoneblood pressurebody indexEditorialsatrial fibrillationPDF download SubjectsHigh