Resistant Hypertension in People With CKD: A Review

• Published in: American journal of kidney diseases Vol. 77; no. 1; pp. 110 - 121
• Main Authors: Fay, Kevin S., Cohen, Debbie L.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.01.2021
• Subjects: Antihypertensive Agents - pharmacology; blood pressure (BP); chronic kidney disease (CKD); Drug Resistance; fibromuscular dysplasia; Humans; Hypertension; Hypertension - complications; Hypertension - therapy; masked hypertension; Medication Therapy Management; renal artery stenosis; Renal Insufficiency, Chronic - complications; Renal Insufficiency, Chronic - physiopathology; resistant hypertension (RH); review; Hypertension; renal artery stenosis; masked hypertension; blood pressure (BP); review; fibromuscular dysplasia; resistant hypertension (RH); chronic kidney disease (CKD)
• ISSN: 0272-6386; 1523-6838
• DOI: 10.1053/j.ajkd.2020.04.017

Resistant hypertension is common in the chronic kidney disease population and conveys increased risk for adverse cardiovascular outcomes and the development of kidney failure. Recently, the American College of Cardiology and 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 for whom antihypertensive therapy fails due to difficulty adhering to complex multidrug 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.