Diabetes and chronic kidney disease: tragedy and challenge

Management of hypertension in diabetic nephropathy is challenging and generally requires a minimum of three different and complementary antihypertensive agents to achieve the recently recommended blood pressure (BP) goal of <130/80 mm Hg in order to reduce cardiovascular (CV) risk and preserve kidney function. Commonly used antihypertensive combinations include an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, agents that have compelling indications for use in diabetic renal disease, added to a diuretic, generally a thiazide-type agent. If additional therapy is required, either a beta-blocker or calcium antagonist may be added. Beta-blockers are particularly effective in people with a high sympathetic drive, i.e. high pulse rates, to lower BP and reduce CV risk while reducing proteinuria and slowing decline of kidney function. In light of this information, it is disturbing that a recent analysis of the NHANES III database indicates that only about 11% of people with diabetic kidney disease have achieved the target BP of <130/80 mm Hg. Recent data from Denmark demonstrate that focusing on total CV risk reduction among people with diabetes, including achievement of recommended BP and lipid goals along with the use of aspirin, exercise and a proper diet, can reduce the absolute risk of a CV event by 20% over less intensive treatment.     

Blood pressure control and physician management of hypertension in hospital hypertension units in Spain

Goal blood pressure (BP) was defined by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) and the World Health Organization-International Society of Hypertension (WHO/ISH) as <140 mm Hg systolic and <90 mm Hg diastolic for the general and <130 mm Hg systolic and <85 mm Hg diastolic for special high-risk populations. However, there are few reports that address BP control among special subgroups of hypertensives by reference to targeted BP. We therefore conducted a study to evaluate BP control of 4049 hypertensives in 47 hospital-based hypertension units in Spain. Overall, 42% of patients achieved goal BP (<140 mm Hg systolic and <90 mm Hg diastolic). Only 13% of diabetic patients and 17% of those with renal disease achieved the BP goal (<130 mm Hg systolic and <85 mm Hg diastolic), and only 10% and 12%, respectively, achieved the even more rigorous goal (<130 mm Hg systolic and <80 mm Hg diastolic). Likewise, only 18% of patients in JNC-VI risk group C and 17% of WHO/ISH high-risk patients attained a goal BP <130 mm Hg systolic and <85 mm Hg diastolic. BP control (<125 mm Hg systolic and <75 mm Hg diastolic) was extremely low (2%) in patients with proteinuria >1 g/d. Poorer BP control was observed among patients at high risk, with diabetes, renal disease, or obesity, than in lower-risk groups. BP control was lower for systolic than for diastolic BP. In >50% of uncontrolled patients, no measures were taken by doctors to optimize pharmacologic treatment, and approximately one-third of patients were still using drug monotherapy. Control of BP, particularly of systolic BP, is still far from optimal in hospital-based hypertension units. Patients at high risk, with diabetes or proteinuria, warrant focused attention. Moreover, a more aggressive behavior of doctors treating uncontrolled hypertension is needed.     

Usefulness of exercise-induced hypertension as predictor of chronic hypertension in adults after operative therapy for aortic isthmic coarctation in childhood

Chronic hypertension is a major concern in adults who have undergone resection of coarctation of the aorta (CoA) in childhood. In otherwise healthy subjects, exercise-induced hypertension is prognostic for chronic hypertension; however, the prognostic value in patients with CoA remains unknown. The aim of the present study was to evaluate the predictive value of exercise-induced hypertension for chronic hypertension in these patients. In the present prospective follow-up study, 74 patients with CoA (58% men, age 30.9 ± 9.5 years) underwent ambulatory blood pressure (BP) monitoring and exercise testing twice from 2001 to 2009 with a follow-up period of 6.3 ± 0.8 years. Hypertension was defined as a mean systolic BP ≥140 mm Hg and/or mean diastolic BP ≥90 mm Hg or the need for antihypertensive treatment. Exercise-induced hypertension was defined as a mean systolic BP of <140 mm Hg and peak exercise systolic BP of ≥200 mm Hg. At baseline, 27 patients (36%) were hypertensive, 11 (15%) had exercise-induced hypertension, and 36 (49%) were normotensive. At follow-up, all 27 hypertensive patients remained hypertensive. Of the 11 with exercise-induced hypertension, 7 (64%) had developed chronic hypertension, and 4 (36%) continued to have exercise-induced hypertension. Of the 36 normotensive patients, 7 (19%) had developed hypertension, 12 (33%) had developed exercise-induced hypertension, and 17 (47%) remained normotensive. On multivariate analysis, baseline maximum exercise systolic BP was independently associated with the mean systolic BP at follow-up (β = 0.13, p = 0.005). In conclusion, the maximum exercise systolic BP was a predictor for chronic hypertension in patients with CoA. These findings demonstrate the clinical importance of exercise-induced hypertension and warrant additional study into the long-term consequences of exercise-induced hypertension and the potential beneficial role of early antihypertensive treatment in adult patients after CoA repair with exercise-induced hypertension.     

Effect of efonidipine and ACE inhibitors on proteinuria in human hypertension with renal impairment

Although several lines of recent studies fail to demonstrate the beneficial action of calcium antagonists, a novel dihydropyridine efonidipine, which possesses dilatory action of both afferent and efferent arterioles and, therefore, shares the renal microvascular action with angiotensin converting enzyme (ACE) inhibitors, is reported to exhibit renal protection in experimental animals.The present study evaluated the effect of efonidipine and ACE inhibitors on blood pressure (BP) and proteinuria. Sixty-eight hypertensive patients with renal impairment (serum creatinine, >1.5 mg/dL) or chronic renal parenchymal disease were randomly assigned to efonidipine or ACE inhibitor treatment. Of the 68 patients, 23 were treated with efonidipine and 20 with ACE inhibitors; these patients were analyzed for the 48-week study.Both efonidipine and ACE inhibitors produced a similar degree of reductions in BP (efonidipine, from 161 +/- 2/93 +/- 2 to 142 +/- 5/82 +/- 2 mm Hg; ACE inhibitor, from 163 +/- 3/95 +/- 2 to 141 +/- 5/83 +/- 2 mm Hg), and maintained creatinine clearance for 48 weeks. Proteinuria tended to decrease in both groups, and a significant reduction was observed in proteinuric patients (>1 g/day) (efonidipine, from 2.7 +/- 0.3 to 2.1 +/- 0.3 g/day; ACE inhibitor, from 3.0 +/- 0.4 to 2.0 +/- 0.5 g/day). Of interest, efonidipine decreased proteinuria in proteinuric patients who failed to manifest decreases in systemic BP. Finally, the incidence of adverse effects, including hyperkalemia and cough, was less in the efonidipine-treated group.Both efonidipine and ACE inhibitors preserved renal function in hypertensive patients with renal impairment. The antiproteinuric effect was apparent in patients with greater proteinuria. The beneficial action of efonidipine, along with fewer side effects, may favor the use of this agent in the treatment of hypertension with renal impairment.     

Prevalence,awareness, and control of arterial hypertension in Denmark

Hypertension is an important modifiable risk factor for cardiovascular disease. Risk is reduced by reduction of blood pressure (BP). The present survey estimated the prevalence of hypertension, awareness, treatment, and BP control in Denmark. BP was measured three times on one occasion in a representative sample (n = 7,767) of the Danish population ages 20 to 89 years. Persons with screening BP ≥140/90 mm Hg also measured BP at home. Participants with home BP ≥135/85 mm Hg in general and ≥125/75 mm Hg for patients with diabetes or renal disease were categorized as hypertensive together with those already on antihypertensive treatment. Awareness was registered by questionnaire. Treated patients with BP below relevant limits were categorized as controlled. Age-adjusted prevalence of hypertension was on the basis of screening BP 25.7% and by home BP 22.3%. Seventy-two percent of patients found hypertensive by home BP were aware of it, 64% were treated, and 57% of those treated were controlled by office BP and 68% by home BP. One-fifth of the adult Danish population was found to be hypertensive, Awareness and control of hypertension was better than in most previous reports. Control rates similar to those of clinical trials are achievable in clinical practice.     

Guidelines for management of hypertension: report of the third working party of the British Hypertension Society.

Use non-pharmacological measures in all hypertensive and borderline hypertensive people. Initiate antihypertensive drug therapy in people with sustained systolic blood pressures (BP) >/=160 mm Hg or sustained diastolic BP >/=100 mm Hg. Decide on treatment in people with sustained systolic BP between 140 and 159 mm Hg or sustained diastolic BP between 90 and 99 mm Hg according to the presence or absence of target organ damage, cardiovascular disease or a 10-year coronary heart disease (CHD) risk of >/=15% according to the Joint British Societies CHD risk assessment programme/risk chart. In people with diabetes mellitus, initiate antihypertensive drug therapy if systolic BP is sustained >/=140 mm Hg or diastolic BP is sustained >/=90 mm Hg. In non-diabetic hypertensive people, optimal BP treatment targets are: systolic BP <140 mm Hg and diastolic BP <85 mm Hg. The minimum acceptable level of control (Audit Standard) recommended is <150/<90 mm Hg. Despite best practice, these levels will be difficult to achieve in some hypertensive people. In diabetic hypertensive people, optimal BP targets are; systolic BP <140 mm Hg and diastolic BP <80 mm Hg. The minimum acceptable level of control (Audit Standard) recommended is <140/<90 mm Hg. Despite best practice, these levels will be difficult to achieve in some people with diabetes and hypertension. In the absence of contraindications or compelling indications for other antihypertensive agents, low dose thiazide diuretics or beta-blockers are preferred as first-line therapy for the majority of hypertensive people. In the absence of compelling indications for beta-blockade, diuretics or long acting dihydropyridine calcium antagonists are preferred to beta-blockers in older subjects. Compelling indications and contraindications for all antihypertensive drug classes are specified. For most hypertensives, a combination of antihypertensive drugs will be required to achieve the recommended targets for blood pressure control. Other drugs that reduce cardiovascular risk must also be considered. These include aspirin for secondary prevention of cardiovascular disease, and primary prevention in treated hypertensive subjects over the age of 50 years who have a 10-year CHD risk >/=15% and in whom blood pressure is controlled to the audit standard. In accordance with existing British recommendations, statin therapy is recommended for hypertensive people with a total cholesterol >/=5 mmol/L and established vascular disease, or 10-year CHD risk >/=30% estimated from the Joint British Societies CHD risk chart. Glycaemic control should also be optimised in diabetic subjects. Specific advice is given on the management of hypertension in specific patient groups, ie, the elderly, ethnic subgroups, diabetes mellitus, chronic renal disease and in women (pregnancy, oral contraceptive use and hormone replacement therapy). Suggestions for the implementation and audit of these guidelines in primary care are provided.     

Ambulatory blood pressure monitoring in patients with chronic kidney disease and resistant hypertension

J Clin Hypertens (Greenwich). 2012; 14:611–617. © 2012 Wiley Periodicals, Inc. The role of ambulatory blood pressure (BP) monitoring (ABPM) has not been well‐studied in patients with chronic kidney disease and resistant hypertension. In a retrospective study of the outpatient chronic kidney disease population, 156 patients with chronic kidney disease and resistant hypertension who had 24‐hour ABPM and clinic BP measurements were identified. Resistant hypertension was defined as uncontrolled clinic BP while taking ≥3 medications including a diuretic or controlled BP while taking ≥4 medications. Within the study group, ambulatory BP <130/80 mm Hg was found in 35.9% of all patients. Only 6.4% had both ambulatory and clinic BP <130/80 mm Hg. Prevalence of white‐coat hypertension, masked hypertension, and sustained hypertension were 29.5%, 5.8%, and 58.3%, respectively. Compared with patients with sustained hypertension, more patients in the white‐coat hypertension group had low nocturnal average systolic BP (defined as nocturnal average systolic BP <100 mm Hg) (17.4% vs 0%) and low 24‐hour average diastolic BP (defined as 24‐hour average diastolic BP <60 mm Hg) (52.2% vs 22%, P<.01). ABPM provides more reliable assessment of BP in patients with chronic kidney disease and resistant hypertension.     

Prevalence and therapeutic control of hypertension in 30,000 subjects in the workplace

-To assess blood pressure (BP) control in a French working population through the use of a careful assessment of BP based on 2 different visits in 1 month, 17 359 men and 12 267 women were evaluated from January 1997 to April 1998. The initial phase was a cross-sectional analysis of a cohort study designed to assess the incidence of arterial hypertension in a French working population. Information was collected by the work-site physician during the annual examination. BP was measured with a validated automatic device. Among subjects with BP >/= mm Hg, patients not treated with antihypertensive drugs were invited to have an additional BP measurement taken 1 month later. The prevalence of hypertension (BP >/= mm Hg) based on 2 visits was 16.2% in men and 9.4% in women. When the diagnosis of hypertension was based on 2 visits, its prevalence was 41% lower in men and 36% lower in women compared with that of a diagnosis based on a single visit. Accordingly, the awareness of hypertension was 49% higher in men and 40% higher in women. Overall, 12.5% of hypertensive men and 33.2% of hypertensive women taking antihypertensive medication had their BP levels lowered to < mm Hg by treatment. Although the percentage of hypertensive men and women under current treatment who were aware of their hypertension increased with age, BP control among treated subjects decreased with age. Ineffective BP control with treatment accounted for 33% of BP levels >/= mm Hg in men and 40% of those observed in women. In this large French working population, estimates of hypertension therapeutic control depend heavily on the number of BP measurements. Despite these methodological precautions, insufficient awareness of BP and insufficient BP control through treatment remain 2 major public health problems.     

Beyond the Usual Strategies for Blood Pressure Reduction: Therapeutic Considerations and Combination Therapies

Rapidly accumulating clinical data have repeatedly demonstrated not only the critical importance of even small increases in blood pressure as a pathophysiologic factor in the development of cardiovascular disease, particularly in individuals with diabetes mellitus, but also the therapeutic necessity of more aggressive blood pressure reduction and the achievement of progressively lower blood pressure targets in reducing cardiovascular event rates. JNC VI has defined optimal blood pressure as ≤120/80 mm Hg, and Stage 1 hypertension as ≥140/80 mm Hg. Target blood pressures are now ≤130/80 mm Hg in patients with diabetes and <125/75 mm Hg for patients with hypertensive renal disease with proteinuria of>1 gm/24 hours. Achieving such target pressures is increasingly difficult, particularly in diabetic patients with chronic renal disease, who require complex multidrug antihypertensive regimens. This review attempts to provide some suggestions for constructing such antihypertensive regimens, and provides considerations for the appropriate use of diuretics and the most effective drug combinations. Factors potentially contributing to drug resistant hypertension include such problems as failure to maximize drug dosing, suboptimal diuretic use, noncompliance, and possible confounding effects of such concomitant medications as nonsteroidal and anti-inflammatory drugs or decongestants. The issues underlying drug-resistant hypertension are listed, together with strategies for overcoming this problem.     

Diabetes and hypertension, the deadly duet: importance, therapeutic strategy, and selection of drug therapy

Large, placebo-controlled RCTs that involve only diabetic patients who have hypertension have not been performed. Subgroup analyses of hyper-tension control from several recent RCTs un-equivocally demonstrated greater benefit in diabetic populations (see Table 3) with ACE inhibitors, TDs, and CCBs. Treatment with fBs(atenolol) also was beneficial in diabetic patients who had hypertension in the actively-controlled UKPDS. The results of three RCTs support intensive BP control in diabetic patients (see Table 4). In these trials, diabetic patients gained more benefit than nondiabetic patients. Such an effect is consistent with the fact that diabetics are at higher risk for CV events. Although there are limited data from RCTs with head-to-head comparison of newer agents (eg,ACE inhibitors, ARBs, CCBs) to show that these drugs are better than diuretics and betaBs in reducing CV events by treating hypertension in the diabetic population, the available data support ACE inhibitors (and ARBs if ACE inhibitors are not tolerated) as an initial drug of choice in diabetic,hypertensive patients (see Table 5). Most diabetic patients require three or four drugs to control their BP to target range; as such, it is not necessary to justify the choice of any single class of drug.Tight BP control is cost-effective and is more rewarding than hyperglycemic control in diabetic,hypertensive patients. The optimal goal in diabetics should be to achieve BP that is less than 130/80 mm Hg. Appropriate action should be taken if BP is greater than 140/85 mm Hg. In subjects who have diabetes and renal insufficiency,the BP should be decreased to less than 125/75 mm Hg to delay the progression of renal failure. Limited data suggest that an ACE inhibitor or an ARB is the agent of choice, especially in patients who have proteinuria or renal insufficiency. betaBs can be the first-line agent in diabetics who have CAD. TDs and CCBs are the second line drugs.AAAs should be avoided. Most hypertensive patients require more than one agent to adequately control their BP. There is no evidence to support one combination regimen over the others, nevertheless, the combination of an ACE inhibitor with a TD or a fPB may be more beneficial and cost effective than other combinations in the diabetic population. Large outcome studies that compare different combination therapies in hypertensive,diabetic patients are needed.     

Cardiovascular outcome in treated hypertensive patients with responder, masked, false resistant, and true resistant hypertension

BACKGROUND: The aim of this study was to evaluate the cardiovascular outcome in apparently responder hypertensive patients with responder and masked hypertension, and in apparently resistant hypertensive patients with false and true resistant hypertension. METHODS: The occurrence of fatal and nonfatal cardiovascular events was evaluated in 340 patients with responder hypertension (clinic blood pressure [BP] <140/90 mm Hg and daytime BP <135/85 mm Hg), 126 with masked hypertension (clinic BP <140/90 mm Hg and daytime BP >135 or 85 mm Hg), 146 with false resistant hypertension (clinic BP >or=140 or 90 mm Hg and daytime BP <135/85 mm Hg), and 130 with true resistant hypertension (clinic BP >or=140 or 90 mm Hg and daytime BP >135 or 85 mm Hg). RESULTS: During follow-up period (4.98 +/- 2.9 years), the event-rate per 100 patient-years was 0.87, 2.42, 1.2, and 4.1 in patients with responder, masked, false resistant, and true resistant hypertension, respectively. After adjustment for several covariates, including clinic BP (forced into the model), Cox regression analysis showed that cardiovascular risk was significantly higher in masked hypertension (masked versus responder hypertension, relative risk [RR] 2.28, 95% confidence interval [CI] 1.1-4.7, P < .05) and in true resistant hypertension (true resistant versus responder hypertension, RR 2.94, 95% CI 1.02-8.41, P < .05), whereas there was no significant difference between false resistant and responder hypertension. CONCLUSIONS: This study shows that patients with masked hypertension are at higher risk than those with responder hypertension, and that those with false resistant hypertension are at lower risk than those with true resistant hypertension. Ambulatory BP monitoring should be performed in treated hypertensive patients to obtain a better prognostic stratification.     

Hypertension in patients with chronic kidney disease

Hypertension is very common in patients with chronic kidney disease (CKD); it causes early loss of kidney function and accelerated cardiovascular morbidity and mortality. African American patients with hypertension and genetic disposition are at an even higher risk for renal disease and ultimately renal failure. Hypertensive patients with CKD should aim for stringent blood pressure (BP) control (target < 130/80 mm Hg) requiring more than one drug with renin-angiotensin-aldosterone system blockade as a component of therapy targeting both hyper tension and proteinuria. Management of hypertension in the dialysis population should focus on ambulatory measurements of BP and the use of longer-acting antihypertensive drugs, with their dosage and timing adjusted according to their dialytic clearances. Hypertension is also common among kidney transplant recipients and contributes to graft loss and premature death. The target BP in transplant recipients is the same as in the CKD population, with no preference for one drug group over another. Unless contraindicated, angiotensin-converting enzyme inhibitors remain the drugs of choice for hypertension in patients with autosomal-dominant polycystic kidney disease, in whom diastolic cardiac dysfunction is a prominent feature.     

Hypertension in African Americans Aged 60 to 79 Years: Statement From the International Society of Hypertension in Blacks

A 2014 hypertension guideline raised goal systolic blood pressure (SBP) from <140 mm Hg to <150 mm Hg for adults 60 years and older without diabetes mellitus (DM) or chronic kidney disease (CKD). The authors aimed to define the status of hypertension in black adults 60 to 79 years from the National Health and Nutrition Examination Survey 2005–2012 and provide practical guidance. Black patients were more often aware and treated (P≤.005) for hypertension than whites and had higher rates of DM/CKD (P<.001), similar control to <140/<90 mm Hg with DM/CKD (P=.59), and lower control without DM/CKD (<140/<90 mm Hg and <150/<90 mm Hg, P≤.01). Limited awareness (<30%) and infrequent health care (>30% 0–1 health‐care visits per year) occurred in untreated black and white hypertensive patients without DM/CKD and BP ≥140/<90 mm Hg. The literature suggests benefits of treated SBP <140 mm Hg in adults 60 to 79 years without DM/CKD. The International Society of Hypertension in Blacks recommends: (1) continuing efforts to achieve BP <140/<90 mm Hg in those with DM/CK, and (2) identifying hypertensive patients without DM/CKD and BP ≥140/<90 mm Hg and treat to an SBP <140 mm Hg in black adults 60–79 years.     

Selective endothelin-A receptor antagonism reduces proteinuria, blood pressure, and arterial stiffness in chronic proteinuric kidney disease

Proteinuria is associated with adverse cardiovascular and renal outcomes that are not prevented by current treatments. Endothelin 1 promotes the development and progression of chronic kidney disease and associated cardiovascular disease. We, therefore, studied the effects of selective endothelin-A receptor antagonism in proteinuric chronic kidney disease patients, assessing proteinuria, blood pressure (BP), and arterial stiffness, key independent, surrogate markers of chronic kidney disease progression and cardiovascular disease risk. In a randomized, double-blind, 3-way crossover study, 27 subjects on recommended renoprotective treatment received 6 weeks of placebo, 100 mg once daily of sitaxsentan, and 30 mg once daily of nifedipine long acting. Twenty-four-hour proteinuria, protein:creatinine ratio, 24-hour ambulatory BP, and pulse wave velocity (as a measure of arterial stiffness) were measured at baseline and week 6 of each treatment. In 13 subjects, renal blood flow and glomerular filtration rate were assessed at baseline and week 6 of each period. Compared with placebo, sitaxsentan reduced 24-hour proteinuria (-0.56±0.20 g/d; P=0.0069), protein:creatinine ratio (-38±15 mg/mmol; P=0.0102), BP (-3.4±1.2 mm Hg; P=0.0069), and pulse wave velocity (-0.64±0.24 m/s; P=0.0052). Nifedipine matched the BP and pulse wave velocity reductions seen with sitaxsentan but did not reduce proteinuria. Sitaxsentan alone reduced both glomerular filtration rate and filtration fraction. It caused no clinically significant adverse effects. Endothelin-A receptor antagonism may provide additional cardiovascular and renal protection by reducing proteinuria, BP, and arterial stiffness in optimally treated chronic kidney disease subjects. The antiproteinuric effects of sitaxsentan likely relate to changes in BP and renal hemodynamics.     

Prevalence, awareness, treatment and control of hypertension in Vietnam-results from a national survey

The objective of this study was to estimate mean blood pressure (BP), prevalence of hypertension (defined as BP ≥140/90?mm?Hg) and its awareness, treatment and control in the Vietnamese adult population. This cross-sectional survey took place in eight Vietnamese provinces and cities. Multi-stage stratified sampling was used to select 9832 participants from the general population aged 25 years and over. Trained observers obtained two or three BP measurements from each person, using an automatic sphygmomanometer. Information on socio-geographical factors and anti-hypertensive medications was obtained using a standard questionnaire. The overall prevalence of hypertension was 25.1%, 28.3% in men and 23.1% in women. Among hypertensives, 48.4% were aware of their elevated BP, 29.6% had treatment and 10.7% achieved targeted BP control (<140/90?mm?Hg). Among hypertensive aware, 61.1% had treatment, and among hypertensive treated, 36.3% had well control. Hypertension increased with age in both men and women. The hypertension was significantly higher in urban than in rural areas (32.7 vs 17.3%, P<0.001). Hypertension is a major and increasing public health problem in Vietnam. Prevalence among adults is high, whereas the proportions of hypertensives aware, treated and controlled were unacceptably low. These results imply an urgent need to develop national strategies to improve prevention and control of hypertension in Vietnam.     

Blood Pressure Targets for Patients with Diabetes or Kidney Disease

The most recent scientific guideline statements from foundations and societies dealing with diabetes and kidney disease argue for blood pressure (BP) goals lower than 130/80 mm Hg, but whether the evidence from properly done clinical trials supports this BP level remains questionable. A review of all the evidence suggests that almost all of the data come from retrospective data analyses of randomized cardiovascular and chronic kidney disease (CKD) trials. Meta-analyses of all clinical trials to date demonstrate that reducing BP reduces risk for stroke and coronary heart disease, but none have achieved a mean BP goal of less than 130/80 mm Hg. In fact, only two prospective trials achieved a BP lower than 130/80 mm Hg in people with type 2 diabetes, as did three trials in advanced proteinuric CKD. Of these, one of the two diabetes trials showed a benefit for overall cardiovascular risk reduction, and two of the three kidney disease trials showed a benefit on slowing of advanced CKD. Of note, however, these two trials in CKD had baseline average proteinuria rates of more than 500 mg/day. No benefit of a lower BP was seen in microalbuminuric CKD. Therefore, the totality of the prospective randomized trial evidence indicates that a BP less than 130/80 mm Hg is not defensible to slow nephropathy progression unless proteinuria levels are at least 500 mg/day, and it does not reduce overall cardiovascular events in diabetes. Stroke benefit was uniformly seen at BP levels less than 130/80 mm Hg, however. Therefore, newer guidelines are emerging that state that the BP goal for most people is lower than 140/90 mm Hg with level IA or IB evidence, and that levels lower than 130/80 mm Hg are defensible only if advanced proteinuric CKD is present or stroke risk is very high (i.e., history of prior stroke or several risk factors for stroke, including hypertension, smoking, diabetes mellitus, dyslipidemia).     

Blood pressure in children with chronic kidney disease: a report from the Chronic Kidney Disease in Children study

To characterize the distribution of blood pressure (BP), prevalence, and risk factors for hypertension in pediatric chronic kidney disease, we conducted a cross-sectional analysis of baseline BPs in 432 children (mean age 11 years; 60% male; mean glomerular filtration rate 44 mL/min per 1.73 m(2)) enrolled in the Chronic Kidney Disease in Children cohort study. BPs were obtained using an aneroid sphygmomanometer. Glomerular filtration rate was measured by iohexol disappearance. Elevated BP was defined as BP >or=90th percentile for age, gender, and height. Hypertension was defined as BP >or=95th percentile or as self-reported hypertension plus current treatment with antihypertensive medications. For systolic BP, 14% were hypertensive and 11% were prehypertensive (BP 90th to 95th percentile); 68% of subjects with elevated systolic BP were taking antihypertensive medications. For diastolic BP, 14% were hypertensive and 9% were prehypertensive; 53% of subjects with elevated diastolic BP were taking antihypertensive medications. Fifty-four percent of subjects had either systolic or diastolic BP >or=95th percentile or a history of hypertension plus current antihypertensive use. Characteristics associated with elevated BP included black race, shorter duration of chronic kidney disease, absence of antihypertensive medication use, and elevated serum potassium. Among subjects receiving antihypertensive treatment, uncontrolled BP was associated with male sex, shorter chronic kidney disease duration, and absence of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use. Thirty-seven percent of children with chronic kidney disease had either elevated systolic or diastolic BP, and 39% of these were not receiving antihypertensives, indicating that hypertension in pediatric chronic kidney disease may be frequently under- or even untreated. Treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may improve BP control in these patients.     

Impact of the Number of Blood Pressure Measurements on Blood Pressure Classification in US Adults: NHANES 1999–2008

J Clin Hypertens (Greenwich). 2012;14:751–759. ©2012 Wiley Periodicals, Inc. Clinical guidelines recommend averaging ≥2 blood pressure (BP) measurements on each visit. Only one BP is measured on many clinical visits, especially if the value is <120/<80 mm Hg, ie, normal. The impact of this practice on accurate assignment of BP category is incompletely defined. Data were analyzed from 22,641 adults 18 years and older who had 3 BP readings in the National Health and Nutrition Examination Surveys 1999–2008. BP category defined by initial measurement was compared with the category determined by mean of the first and second, first through third, and second and third readings. Among 8553 nonhypertensive patients with initial BP <120/<80 mm Hg, 2.9%, 3.3%, and 6.7%, respectively, were reclassified as prehypertensive, ie, BP 120–139/80–89 mm Hg, and two patients as stage 1 hypertension (140–159/90–99 mm Hg). In 733 treated hypertensive patients with initial BP <120/<80 mm Hg, 5.1%–8.9% were reclassified as prehypertensive and only one patient as hypertensive. Among nonhypertensive and hypertensive patients with initial BP in the prehypertensive range, 8.0%–23.6% were reclassified as normal. Among stage 1 and 2 hypertensive patients based on initial BP, 18.2%–33.5% were reclassified to lower BP categories. By multivariable logistic regression, older age and higher systolic and diastolic BP were associated with reclassification to a lower BP category. In nonhypertensive and hypertensive patients with normal initial BP values, one BP measurement appears adequate as <10% are re‐classified as prehypertensive and <0.5% as hypertensive. In contrast, patients with an initial BP above normal are often reclassified to a lower category, which supports recommendations for additional measurements.     

Renoprotective effect of losartan in comparison to amlodipine in patients with chronic kidney disease and hypertension--a report of the Japanese Losartan Therapy Intended for the Global Renal Protection in Hypertensive Patients (JLIGHT) study.

A 12-month, multicenter (57 clinical institutions), randomized, open-labeled trial was undertaken to compare the efficacy of the angiotensin II receptor antagonist losartan and the calcium channel blocker amlodipine in patients with proteinuric chronic kidney disease (CKD) and hypertension. A total of 117 patients (79, chronic glomerulonephritis; 14, diabetic nephropathy; 24, other CKD) were randomly allocated into two treatment groups. Losartan and amlodipine exerted the same efficacy for blood pressure (BP) control; however, losartan significantly reduced the 24-h urinary protein excretion at months 3, 6, and 12, with the reduction of 20.7%, 35.2%, 35.8%, whereas amlodipine did not change the amount of proteinuria over the 12-month study period. When patients were stratified into groups according to the level of BP control at 3 months, the reduction in urinary protein excretion by losartan was evident in the group for which a BP of <140/90 mmHg was achieved, as well as in the group for which the goal BP (<130/85 mmHg) for treatment of CKD was not achieved. When patients were stratified according to baseline urinary protein excretion, those with > or = 2 g/day showed a reduction in proteinuria by losartan of 23.3%, 39.4%, and 47.9% at months 3, 6, and 12, and those with <2 g/day showed a reduction of 18.5% and 31.2% at months 3 and 6, respectively. No fatal adverse events were experienced in either drug group. We conclude that losartan reduced proteinuria in patients with CKD and hypertension. This positive effect may contribute to the renal protective benefit of losartan, and is beyond the magnitude of BP control.     

Prevalence, Treatment, and Control of Hypertension in the French Population: Data From a Survey on High Blood Pressure in General Practice, 1994

A survey was conducted in a cohort of 235 general practitioners (GP) selected by Sofres Médical who were representative of the French medical population, to measure the percentage of patients with hypertension, treated hypertensives and patients with controlled hypertension. Data were collected over 1 week of office consultation. Practitioners were initially instructed to use the same type of mercury sphygmomanometer, equipped with pneumatic cuffs of different sizes. Three consecutive blood pressure (BP) measurements were made and the last two were recorded. Practitioners had to carry out their own survey over a period of 1 week on all patients > 18 years of age who visited their offices. Patients were considered as hypertensive (HP) if the mean of the two recorded BP measurements was ≥ 140/90 mm Hg or if they were taking antihypertensive drug treatment. Three cutoff points were used to define controlled hypertension: < 140/90 mm Hg (overall population of HP), < 160/95 mm Hg (HP < 65 years of age), and < 160/90 mm Hg (HP ≥ 65 years of age).Among 12,351 patients (mean age, 48.6 years; women, 58%), 5020 were HP, (41%) of whom 2035 were without treatment (41%) and 2985 were receiving antihypertensive drug treatment (59%).Two hundred-thirty patients (4.6%) remained at high risk with moderate or severe hypertension (BP ≥ 180 [systolic] or 105 [diastolic] mm Hg), ie, 1 patient/week/GP.The study confirms the high prevalence of hypertension in general practice and shows that 7 of 10 patients have an acceptable control of their BP (< 160/95 or < 160/90 mm Hg according to age) but only 24% of treated HP achieved the target of a BP level < 140/90 mm Hg, representing 28% of the 18 to 64 year old group and 21% of the elderly group.French GP did not choose an optimal control, and the medical community is waiting for answers to crucial questions, ie, does optimal BP control significantly improve the absolute cardiovascular risk? How far should blood pressure be lowered?