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HYPERTENSION
Kidney Diseases and Blood Pressure
Mohammad Ilyas, M.D.
Assistant Clinical Professor
University of Florida / Health Sciences Center
Jacksonville, Florida USA
1
7/2/2014
Outline
1. Definition, Regulation and Pathophysiology
2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory
Blood Pressure Monitoring
3. Evaluation of Primary Versus Secondary
4. Sequel of Hypertension and Hypertension Emergencies
5. Management of Hypertension (Non-Pharmacology versus Drug Therapy)
6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep
Disorders.
7. Hypertension in Renal diseases and Pregnancies
8. Pediatric, Neonatal and Genetic Hypertension
2
Kidney and blood pressure
7/2/2014
3
Kidney Diseases and Blood Pressure
Definition and epidemiology
Prevalence of HTN with CKD
Pathogenesis
Risk factors for progression
Therapy of HTN with CKD
HTN with ESRD
7/2/2014
4
What proportion of adult population
has CKD ?
1. One in four
2. One in eight
3. One in ten
4. One in twenty
7/2/2014
5
What proportion of adult population
has CKD ?
1. One in four
2. One in eight
3. One in ten
4. One in twenty
7/2/2014
6
INTRODUCTION
 CKD = GFR < 60 mL/min/m2
 24.5 % of 60 years and older
has CKD -2006.
 13.1% (1/8) of adult USA
population has CKD
 27 Millions
7/2/2014
7
How does high blood pressure affect the
kidneys?
• High blood pressure can damage blood vessels
by causing scaring and weaken the vessel wall.
• It decrease the GFR  fluid retention 
hypertension  renal damage
• 2nd leading cause of renal failure
7/2/2014
8
Causes of kidney failure in the United
States
7/2/2014
9
Stages of CKD
7/2/2014
10
Stage GFR* Description
1 90+ Normal kidney function but urine findings or
structural abnormalities or genetic trait point to
kidney disease
2 60-89 Mildly reduced kidney function, and other
findings (as for stage 1) point to kidney disease
3A
3B
45-59
30-44
Moderately reduced kidney function
4 15-29 Severely reduced kidney function
5 <15 or on
dialysis
Very severe, or end stage kidney failure
The primary cause of death in CKD is?
A. Infection
B. Cardio Vascular Disease
C. Kidney failure
D. Malignancies
7/2/2014
11
The primary cause of death in CKD is?
A. Infection
B. Cardio Vascular Disease
C. Kidney failure
D. Malignancies
7/2/2014
12
Why CKD Patient have CVD?
30-50% INFLAMATION (increased CRP, increase IL-6,
decrease albumin)
CRP is a marker for CVD
CKD have metastatic calcification (increase PTHi,
Ca, PO4 level)
 Hyperlipidemia
 Hypertension
 Anemia
7/2/2014
13
Hypertension in CKD
23.3% of individuals without CKD, and
35.8% of stage 1,
48.1% of stage 2,
59.9% of stage 3, and
84.1% of stage 4-5 CKD patients
7/2/2014
14
PATHOGENESIS
The pathogenesis of hypertension varies with the
type of disease
Glomerular versus Vascular
&
Acute versus Chronic
7/2/2014
15
Acute glomerular disease
Acute glomerular disease, (e.g.
poststreptococcal glomerulonephritis)
Increase Blood pressure is primarily due to fluid
overload (as evidenced by suppression of the RAAS
and enhanced release of atrial natriuretic peptide)
Fluid overload is due to Na retention, Na+ retention is
due to increased reabsorption in the collecting
tubules.
7/2/2014
16
Acute glomerular disease
Two different abnormalities in collecting tubule
function have been identified in glomerular disease,
both of which could increase sodium reabsorption:
Relative resistance to Atrial Natriuretic Peptide, (ANP)
due at least in part to more rapid degradation of the
second messenger cyclic GMP by the enzyme
phosphodiesterase .
Increased activity of the Na-K-ATPase pump in the
cortical collecting tubule but not other nephron
segments . This pump provides the energy for active
sodium transport by pumping reabsorbed sodium out
the cell into the peritubular capillary.
7/2/2014
17
Acute vascular disease
 Hypertension is also common in acute vascular diseases,
such as vasculitis or scleroderma renal crisis.
 In these settings, the elevation in blood pressure results
from ischemia-induced activation of the renin-
angiotensin system rather than volume expansion
 This difference in mechanism between glomerular and
vascular disease may be of therapeutic importance
7/2/2014
18
PATHOGENESIS
1. Sodium and volume excess due to diminished
sodium excretory capacity.
2. Activation of the renin-angiotensin-aldosterone
system due to primary vascular disease or to
regional ischemia induced by scarring.
3. Increased activity of the sympathetic nervous
system.
4. An increase in endothelium-derived
vasoconstrictors (such as endothelin)
7/2/2014
19
PATHOGENESIS
5. A reduction in endothelium-derived
vasodilators (such as nitric oxide).
6. The administration of erythropoietin (EPO).
7. An increase in intracellular calcium induced by
PTH excess.
8. Calcification of the arterial tree.
9. Preexistent primary hypertension.
7/2/2014
20
Angiotensin and CKD
Angiotensin, which is a protein, is a component of
the renin-angiotensin-aldosterone system (RAAS),
which performs important functions in the
regulation of fluid balance and blood pressure in
the human body.
It has two forms:
Angiotensin I (AI) and Angiotensin II (AG II).
Generally, the function of angiotensin is to raise
the blood pressure. 7/2/2014
21
7/2/2014
22
7/2/2014
23
Addition to the factors
Patients with end-stage renal disease are more
likely to have an increase in central pulse
pressure and isolated systolic hypertension.
Patients with chronic kidney disease may not
demonstrate the normal nocturnal decline in
blood pressure (such patients are called
"nondippers"),
7/2/2014
24
TREATMENT OF HTN IN CKD
Treatment of even mild hypertension is
important in patients with chronic kidney
disease (CKD) to protect against both
1. Progressive renal function loss and
2. Cardiovascular disease, the incidence of
which is increased with mild to moderate
CKD
7/2/2014
25
Goal of BP when treating a patient
with proteinuria is?
A.< 160/100
B.< 140/90
C.< 130/80
D.< 115/70
7/2/2014
26
Goal of BP when treating a patient
with proteinuria is?
A.< 160/100
B.< 140/90
C.< 130/80
D.< 115/70
7/2/2014
27
Goal blood pressure
 Management of blood pressure in chronic kidney
disease that goal blood pressure depends upon the
degree of proteinuria:
 Proteinuric CKD, (500 mg/day or higher),
the BP < 130/80 mmHg.
 Nonproteinuric CKD, (<500 mg/day),
the BP < 140/90 mmHg.
 Isolated systolic HTN, systolic pressure <150 mmHg
 Proteinuria goal of less than 1000 mg/day
7/2/2014
28
BP measurement in CKD
 24-hour ambulatory blood pressure is a stronger
predictor of end-stage renal disease (ESRD),
cardiovascular disease, and death than office-based
measurements
 A daytime ambulatory systolic pressure greater than 145
mmHg was associated with a threefold increased risk of
developing cardiovascular disease and a nearly twofold
increased risk of ESRD or death compared with patients
whose daytime systolic pressure was 126 to 135 mmHg.
 The prognostic value of nighttime ambulatory blood
pressure was even stronger
7/2/2014
29
Management
1. Sodium restriction
2. Diuretics
1. Thiazide diuretics become less effective when the GFR is less than 30
mL/min
2. Loop diuretics are preferred as initial therapy
3. Antihypertensive therapy in proteinuric CKD
1. angiotensin inhibitors as first-line therapy
2. CCB and diuretic with ACE or ARB
4. Antihypertensive therapy in non-proteinuric CKD
1. with edema, initial therapy with a loop diuretic
2. without edema, an ACE, and then add a dihydropyridine CCB
5. Benefit from nocturnal therapy 7/2/2014
30
Hypertension in ESRD
There are several major issues to consider when
approaching hypertension in dialysis patients
1.What is the pathogenesis of the elevation in
blood pressure (BP)?
2.How is hypertension best defined?
3.What are the target BP goals?
4.How should the hypertension be treated?
7/2/2014
31
Hypertension and ESRD
7/2/2014
32
Hypertension in ESRD
 Over 50 to 60 percent of hemodialysis
 Nearly 30 percent of peritoneal dialysis patients are
hypertensive
 Volume overload
7/2/2014
33
Quiz
Test your knowledge
7/2/2014
34
Quiz 1. Goal of BP when treating a
patient with proteinuria is?
A.< 160/100
B.< 140/90
C.< 130/80
D.< 115/70
7/2/2014
35
Quiz 1. Goal of BP when treating a
patient with proteinuria is?
A.< 160/100
B.< 140/90
C.< 130/80
D.< 115/70
7/2/2014
36
Quiz 2. What proportion of adult
population has CKD ?
1. One in four
2. One in eight
3. One in ten
4. One in twenty
7/2/2014
37
Quiz 2. What proportion of adult
population has CKD ?
1. One in four
2. One in eight
3. One in ten
4. One in twenty
7/2/2014
38
Quiz 3. The primary cause of death in
CKD is?
A. Infection
B. Cardio Vascular Disease
C. Kidney failure
D. Malignancies
7/2/2014
39
Quiz 3. The primary cause of death in
CKD is?
A. Infection
B. Cardio Vascular Disease
C. Kidney failure
D. Malignancies
7/2/2014
40
Quiz 4. The pathogenesis of hypertension in
glomerular disease includes all EXCEPT?
A. Increase Blood pressure is primarily due to fluid
overload.
B. Fluid overload is due to Na retention
C. Relative resistance to atrial natriuretic peptide
D. Increased activity of the Na-K-ATPase pump
E. Blood pressure results from ischemia-induced activation
of the renin-angiotensin system
7/2/2014
41
Quiz 4. The pathogenesis of hypertension in
glomerular disease includes all EXCEPT?
A. Increase Blood pressure is primarily due to fluid
overload.
B. Fluid overload is due to Na retention
C. Relative resistance to atrial natriuretic peptide
D. Increased activity of the Na-K-ATPase pump
E. Blood pressure results from ischemia-induced activation
of the renin-angiotensin system
7/2/2014
42

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Hypertension and renal diseases

  • 1. HYPERTENSION Kidney Diseases and Blood Pressure Mohammad Ilyas, M.D. Assistant Clinical Professor University of Florida / Health Sciences Center Jacksonville, Florida USA 1 7/2/2014
  • 2. Outline 1. Definition, Regulation and Pathophysiology 2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory Blood Pressure Monitoring 3. Evaluation of Primary Versus Secondary 4. Sequel of Hypertension and Hypertension Emergencies 5. Management of Hypertension (Non-Pharmacology versus Drug Therapy) 6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep Disorders. 7. Hypertension in Renal diseases and Pregnancies 8. Pediatric, Neonatal and Genetic Hypertension 2
  • 3. Kidney and blood pressure 7/2/2014 3
  • 4. Kidney Diseases and Blood Pressure Definition and epidemiology Prevalence of HTN with CKD Pathogenesis Risk factors for progression Therapy of HTN with CKD HTN with ESRD 7/2/2014 4
  • 5. What proportion of adult population has CKD ? 1. One in four 2. One in eight 3. One in ten 4. One in twenty 7/2/2014 5
  • 6. What proportion of adult population has CKD ? 1. One in four 2. One in eight 3. One in ten 4. One in twenty 7/2/2014 6
  • 7. INTRODUCTION  CKD = GFR < 60 mL/min/m2  24.5 % of 60 years and older has CKD -2006.  13.1% (1/8) of adult USA population has CKD  27 Millions 7/2/2014 7
  • 8. How does high blood pressure affect the kidneys? • High blood pressure can damage blood vessels by causing scaring and weaken the vessel wall. • It decrease the GFR  fluid retention  hypertension  renal damage • 2nd leading cause of renal failure 7/2/2014 8
  • 9. Causes of kidney failure in the United States 7/2/2014 9
  • 10. Stages of CKD 7/2/2014 10 Stage GFR* Description 1 90+ Normal kidney function but urine findings or structural abnormalities or genetic trait point to kidney disease 2 60-89 Mildly reduced kidney function, and other findings (as for stage 1) point to kidney disease 3A 3B 45-59 30-44 Moderately reduced kidney function 4 15-29 Severely reduced kidney function 5 <15 or on dialysis Very severe, or end stage kidney failure
  • 11. The primary cause of death in CKD is? A. Infection B. Cardio Vascular Disease C. Kidney failure D. Malignancies 7/2/2014 11
  • 12. The primary cause of death in CKD is? A. Infection B. Cardio Vascular Disease C. Kidney failure D. Malignancies 7/2/2014 12
  • 13. Why CKD Patient have CVD? 30-50% INFLAMATION (increased CRP, increase IL-6, decrease albumin) CRP is a marker for CVD CKD have metastatic calcification (increase PTHi, Ca, PO4 level)  Hyperlipidemia  Hypertension  Anemia 7/2/2014 13
  • 14. Hypertension in CKD 23.3% of individuals without CKD, and 35.8% of stage 1, 48.1% of stage 2, 59.9% of stage 3, and 84.1% of stage 4-5 CKD patients 7/2/2014 14
  • 15. PATHOGENESIS The pathogenesis of hypertension varies with the type of disease Glomerular versus Vascular & Acute versus Chronic 7/2/2014 15
  • 16. Acute glomerular disease Acute glomerular disease, (e.g. poststreptococcal glomerulonephritis) Increase Blood pressure is primarily due to fluid overload (as evidenced by suppression of the RAAS and enhanced release of atrial natriuretic peptide) Fluid overload is due to Na retention, Na+ retention is due to increased reabsorption in the collecting tubules. 7/2/2014 16
  • 17. Acute glomerular disease Two different abnormalities in collecting tubule function have been identified in glomerular disease, both of which could increase sodium reabsorption: Relative resistance to Atrial Natriuretic Peptide, (ANP) due at least in part to more rapid degradation of the second messenger cyclic GMP by the enzyme phosphodiesterase . Increased activity of the Na-K-ATPase pump in the cortical collecting tubule but not other nephron segments . This pump provides the energy for active sodium transport by pumping reabsorbed sodium out the cell into the peritubular capillary. 7/2/2014 17
  • 18. Acute vascular disease  Hypertension is also common in acute vascular diseases, such as vasculitis or scleroderma renal crisis.  In these settings, the elevation in blood pressure results from ischemia-induced activation of the renin- angiotensin system rather than volume expansion  This difference in mechanism between glomerular and vascular disease may be of therapeutic importance 7/2/2014 18
  • 19. PATHOGENESIS 1. Sodium and volume excess due to diminished sodium excretory capacity. 2. Activation of the renin-angiotensin-aldosterone system due to primary vascular disease or to regional ischemia induced by scarring. 3. Increased activity of the sympathetic nervous system. 4. An increase in endothelium-derived vasoconstrictors (such as endothelin) 7/2/2014 19
  • 20. PATHOGENESIS 5. A reduction in endothelium-derived vasodilators (such as nitric oxide). 6. The administration of erythropoietin (EPO). 7. An increase in intracellular calcium induced by PTH excess. 8. Calcification of the arterial tree. 9. Preexistent primary hypertension. 7/2/2014 20
  • 21. Angiotensin and CKD Angiotensin, which is a protein, is a component of the renin-angiotensin-aldosterone system (RAAS), which performs important functions in the regulation of fluid balance and blood pressure in the human body. It has two forms: Angiotensin I (AI) and Angiotensin II (AG II). Generally, the function of angiotensin is to raise the blood pressure. 7/2/2014 21
  • 24. Addition to the factors Patients with end-stage renal disease are more likely to have an increase in central pulse pressure and isolated systolic hypertension. Patients with chronic kidney disease may not demonstrate the normal nocturnal decline in blood pressure (such patients are called "nondippers"), 7/2/2014 24
  • 25. TREATMENT OF HTN IN CKD Treatment of even mild hypertension is important in patients with chronic kidney disease (CKD) to protect against both 1. Progressive renal function loss and 2. Cardiovascular disease, the incidence of which is increased with mild to moderate CKD 7/2/2014 25
  • 26. Goal of BP when treating a patient with proteinuria is? A.< 160/100 B.< 140/90 C.< 130/80 D.< 115/70 7/2/2014 26
  • 27. Goal of BP when treating a patient with proteinuria is? A.< 160/100 B.< 140/90 C.< 130/80 D.< 115/70 7/2/2014 27
  • 28. Goal blood pressure  Management of blood pressure in chronic kidney disease that goal blood pressure depends upon the degree of proteinuria:  Proteinuric CKD, (500 mg/day or higher), the BP < 130/80 mmHg.  Nonproteinuric CKD, (<500 mg/day), the BP < 140/90 mmHg.  Isolated systolic HTN, systolic pressure <150 mmHg  Proteinuria goal of less than 1000 mg/day 7/2/2014 28
  • 29. BP measurement in CKD  24-hour ambulatory blood pressure is a stronger predictor of end-stage renal disease (ESRD), cardiovascular disease, and death than office-based measurements  A daytime ambulatory systolic pressure greater than 145 mmHg was associated with a threefold increased risk of developing cardiovascular disease and a nearly twofold increased risk of ESRD or death compared with patients whose daytime systolic pressure was 126 to 135 mmHg.  The prognostic value of nighttime ambulatory blood pressure was even stronger 7/2/2014 29
  • 30. Management 1. Sodium restriction 2. Diuretics 1. Thiazide diuretics become less effective when the GFR is less than 30 mL/min 2. Loop diuretics are preferred as initial therapy 3. Antihypertensive therapy in proteinuric CKD 1. angiotensin inhibitors as first-line therapy 2. CCB and diuretic with ACE or ARB 4. Antihypertensive therapy in non-proteinuric CKD 1. with edema, initial therapy with a loop diuretic 2. without edema, an ACE, and then add a dihydropyridine CCB 5. Benefit from nocturnal therapy 7/2/2014 30
  • 31. Hypertension in ESRD There are several major issues to consider when approaching hypertension in dialysis patients 1.What is the pathogenesis of the elevation in blood pressure (BP)? 2.How is hypertension best defined? 3.What are the target BP goals? 4.How should the hypertension be treated? 7/2/2014 31
  • 33. Hypertension in ESRD  Over 50 to 60 percent of hemodialysis  Nearly 30 percent of peritoneal dialysis patients are hypertensive  Volume overload 7/2/2014 33
  • 35. Quiz 1. Goal of BP when treating a patient with proteinuria is? A.< 160/100 B.< 140/90 C.< 130/80 D.< 115/70 7/2/2014 35
  • 36. Quiz 1. Goal of BP when treating a patient with proteinuria is? A.< 160/100 B.< 140/90 C.< 130/80 D.< 115/70 7/2/2014 36
  • 37. Quiz 2. What proportion of adult population has CKD ? 1. One in four 2. One in eight 3. One in ten 4. One in twenty 7/2/2014 37
  • 38. Quiz 2. What proportion of adult population has CKD ? 1. One in four 2. One in eight 3. One in ten 4. One in twenty 7/2/2014 38
  • 39. Quiz 3. The primary cause of death in CKD is? A. Infection B. Cardio Vascular Disease C. Kidney failure D. Malignancies 7/2/2014 39
  • 40. Quiz 3. The primary cause of death in CKD is? A. Infection B. Cardio Vascular Disease C. Kidney failure D. Malignancies 7/2/2014 40
  • 41. Quiz 4. The pathogenesis of hypertension in glomerular disease includes all EXCEPT? A. Increase Blood pressure is primarily due to fluid overload. B. Fluid overload is due to Na retention C. Relative resistance to atrial natriuretic peptide D. Increased activity of the Na-K-ATPase pump E. Blood pressure results from ischemia-induced activation of the renin-angiotensin system 7/2/2014 41
  • 42. Quiz 4. The pathogenesis of hypertension in glomerular disease includes all EXCEPT? A. Increase Blood pressure is primarily due to fluid overload. B. Fluid overload is due to Na retention C. Relative resistance to atrial natriuretic peptide D. Increased activity of the Na-K-ATPase pump E. Blood pressure results from ischemia-induced activation of the renin-angiotensin system 7/2/2014 42