Blood pressure and CKD: the lower the better? JM ...
Transcript of Blood pressure and CKD: the lower the better? JM ...
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Blood pressure and CKD:
the lower the better?
JM Krzesinski
Nephrology department
CHU Liège
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Krzesinski J-M and Cohen E., Acta Clinica Belgica 2007, 62, 5-14.
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Role of salt
retention
Endothelial
dysfunction
Sympathetic
and RAS
systems
activation
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K/DOQI Clinical Practice guidelines, Executive Summary, October 2003.
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Meta-analysis 123 studies (>600000 pts) : 10 mmHg lower
SBP lower all-cause mortality Ettehad et al. Lancet 2016, p957
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Questions
• What is the optimal level of BP in CKD
patients for preventing CV events and
kidney disease progression?
• Is this BP target influenced by proteinuria or
aging?
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Klag et al, NEJM 1996
Age-Adjusted Rate of ESRD Due to Any Cause per 100.000 Person-Years, According to Systolic and Diastolic BP in 332.544 Men Screened for MRFIT
stage 2 HTA
ESRD
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16129 CKD patients FU 3y
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O’Seaghdha C. et al., Hypertension, 2009, 54, 509-515.
560352 pts, FU 6.8y
420 renal deaths
HR 1.84 for each
19 mmHg increase of SBP
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For CKD not on dialysis, until 2015, the guidelines were:
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AASK
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AASKUsual BP 141/85
Strict BP 128/78
ESRD DEATH
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130 vs 141
mmHg
131 vs 134
mmHg
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140/90 vs 125/75
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132 vs
140
mmHg
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New US guidelines November 2017
BP goal
<130/80 mmHg
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SPRINT (NEJM Nov 2015)
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SPRINT: 2 BP goals: <120/80 and <140/90 mmHg
No placebo
BP at the beginning 140/78 mmHg
Difference in BP at the end 15/8 mmHg
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Nov 2015
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121 vs 136 mmHg
CV
Death
70 vs
95
Kidney
outcome
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Harm of anti-hypertensive treatment
26
Hyperkalemia
Hyponatremia
Hypotension
Acute Kidney Injury(but complete reversal in 90%!)*
Syncope/fallsRocco et al. AJKD 2018, p352
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SPRINT AKI
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SPRINT
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ESH 2018
HTA management
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ESH 2018
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Albuminuria
Low birth weight
ADPKD
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CV
Kidney
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CONCLUSIONS in HTA with CKD :
individualization of the BP target!
• BP lowering is a critical component of preventing mortality, CKD progression and CV complications among those with CKD
• Evidence supports at least a goal BP <140/90 mmHg (Level I A/B)
• The exception to this statement is if albuminuria is present, <130/80 mmHg can then be supported for CKD slower (Level II B)
• In oldest patients (>75) a BP target not lower than 140 mmHg must be proposed.
• ABPM should be used to test the 24h BP control
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Thank you
Questions?
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• Proteinuria
• Young age
• When achieved with low treatment burden
• Stroke prevention
• High CV risk (but what about atherosclerotic
coronary heart disease?)
Who benefits from more stringent BP control?
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Caution on Diastolic BP <55 mmHg (SPRINT)
46Kahn et al. Hypertension 2018, p840
25% higher hazard