Hypertension (HTN) is increase blood pressure above the normal value of 120/80mmHg.Increasing prevalence of high blood pressure with age. Pathological changes that appear in blood vessels and heart causing by persistence and chronic elevated blood pressure. Usually, hypertension is asymptomatic. However, long term high blood pressure is a major risk for stork, coronary artery diseases, arterial fibrillation, heart failure ,peripheral artery disease ,chronic kidney disease and dementia .Stages of hypertension :optimal systolic >120mmHg and diastolic >80 mmHg ,Normal: systolic 120-129 mmHg and/or diastolic 80-84mmHg,High normal :systolic 130-139mmHg and /or diastolic 85-89mmHg,stage1:systolic 140-159mmHg and /or diastolic 90-99 mmHg,stage2:systolic 160-179mmHg and /or diastolic 100-109 mmHg,stage3:systolic ≥ 180mm Hg and/ or diastolic ≥110mmHg, Isolated systolic hypertension when systolic ≥ 140mm Hg and/ or diastolic ≤110mmHg.Its classifies into two types based on various factors -Primary hypertension and secondary hypertension. By definition, there is no causative factors for primary (essential) hypertension and most of the adult in are this category. However, research indicates there is risk factors which can increase blood pressure like a genetic, age , diet (eating too much salt), life style include chronic alcoholism , smoking , lack of physical activity , stress. Some people have high blood pressure due to underling conditions, this called secondary hypertension. Many conditions and medications can lead to secondary hypertension, including: complications of diabetes, kidney disease, thyroid diseases, obesity and pregnancy, sleep apnea, pheochromocytoma, congenital adrenal hyperplasia , causing syndrome. And depending on basic medical condition that cause secondary hypertension, it can lead to various complications, including vision loss , heart failure , kidney damage ,aneurysm ,stroke and certain drugs including :contraceptive bills , amphetamines , cocaine .When high blood pressure not control even with despite use of 3 or more than antihypertensive medications this called resistant hypertension and this people have a greater chance of cardiovascular complications than other. Most people with hypertension asymptomatic, in rare cases of hypertension may notice; sweating, anxiety, sleeping disturbance. If BP become
>180/120mmHg this called hypertensive crises and a person may experienced headache, nosebleed, required urgent and immediate hospital care to prevent any permeant organ damage. It is necessary to check blood pressure regularly to avoid any complications. Hypertenstion common in patient with CKD , prevalence range estimate 60% to 90% depending of CKD stages and its cause. Hypertension and chronic kidney disease (CKD)are closely related pathophysiological conditions, such a continued high blood pressure can lead to deterioration of kidney failure and progressive deterioration of kidney function can lead to worsening blood pressure control .The pathophysiological of hypertension in chronic kidney disease is complex which is result of various factors ,including increase sodium retention and expansion extracellular ,low nephron mass and an overactive nervous system sympathetic, stimulating hormones, including renin system -angiotensin -aldosterone system and endothelial dysfunction .For most of patient with CKD not on dialysis ,the target of systolic BP<120mmHg.Main methods to manage high blood pressure in kidney patients ,reduce food salt and start ACE inhibitors or angiotensin receptor blockers and diuretic therapy. Uncontrol high blood pressure can lead to rapid progress of end stage kidney disease, morbidity, and cardiovascular mortality as well. Resistant hypertension in CKD patient is common especially in stage 4 and 5, where required multiple anti-hypertensive agent to achieve the BP target.
Recommendation for CKD patient and general population of reduce in dietary sodium intake can lead to control BP in short term and decrease antihypertensive medications used. As per KIDIGO guideline, recommend reducing salt intake to less than 2 g per day (less than 90 mmol) of sodium per day equivalent to 5 g of sodium chloride in adults. Also reduce sodium intake has the additional benefit of reducing proteinuria in CKD patients. This recommendation usually not suitable for patient with sodium wasting nephropathy. Advised for patients with hypertension and CKD, to do physical activity at least 150 minutes per week as tolerance ,keep in mind cardiorespiratory fitness, physical limitation and cognitive function and fall risk during physical activity in individual patients . Other lifestyle intervention, including weight loss, reduce alcohol
consumption and adopt a healthy diet for a heart shown to reduce BP in general people and CKD patients.
ACE inhibitors and angiotensin receptor blockers (RASi)are firs line therapy in patient with albuminuria or proteinuria. additional of diuretic may helpful in a a combination with ACE inhibitors and angiotensin receptor blockers to decrease the risk of hyperkalemia, patient with CKD received this regimen of therapy required monitoring of Potassium level ,serum creatinine and changes in BP within 2-4 weeks of initiation or increase in the dose of ACE inhibitors and angiotensin receptor blockers .Keep in mind decreae the dose /or stop taking of ACE or angiotension recptors blockers if you have any symptoms of uncontrolled hypotenstion or hyperkalemia or to decrease uremic symptoms while treatment or renal failure (estimate GFR<15ml/min per 1.73m2). Calcium channel blockers are frequently used for treatment of resistant hypertension in dialysis patient like amlodipine, nifedipine, diltizem , verapamil ). As salt and water retention a key factor that contribute to high BP in CKD patient, diuretics medications. an important effect in controlling BP in this situation like thiazides and frusemide. In CKD patients whose under beta blockers therapy to decrease BP, can lead to some side effect such as cardiac arrhythmia. Alpha blockers , the most widely in treatment of high blood pressure and supportive treatment for hypertension with CKD patients or lack of tolerance of other antihypertensive drugs like ACE inhibitors , angiotensin receptor blockers , beta blocker ,diuretics , calcium channel blockers. Alpha blockers may also be benefit if there are symptoms of enlarged prostate.
Blood pressure and volume control are important and critical component in hemodialysis care, and it has great effects of patient symptoms, cardiovascular complications, and quality of life. Pre and post blood pressure measurement during dialysis session are inaccurate value of intradialytic blood pressure and should not used for diagnostic/management of hypertension.
However, pre, post and intradialytic blood pressure measurements have a clinical significance to assess and mange hemodynamical status during hemodialysis. During dialysis treatment, BP drops from pre -dialysis to post- and the value of this reduction closely related to UF removed
in the same dialysis session. Intradialytic hypertension is increasing blood pressure during or immediately after dialysis session and estimate prevalence ranges of intradialytic hypertension5% to 15% in dialysis patients. Increased systolic BP >10mmHg from pre to post dialysis in hypertensive range in 4to 6 consecutive dialysis session required extensive evaluation of BP and volume management, including close assessment of dry weight. In clinical practice, the dry weight is defined a normal body weight without extra fluid. Most dialysis patient are advised to limit the increase weight gain no more than 1kg per day. according to studies, Dialysis management for hypertension starts by monitoring volume overload/ultrafiltration rate(UF), options including increasing treatment time and /or frequency of hemodialysis ,decreasing interdialytic weight gain ( IDWG) . The various signs and symptoms are related to volume overload or depletion like, edema, shortness of breath, cardiomegaly, lung congestion, increase jugular venous pressure, thirst, cramps, light-headedness, weight gain and loss. Patient with hypertension in dialysis should be involved, educated, and encourage to report symptoms routinely and respect dialysis prescription regarding time/frequency and UF rate. Studies indicate that the use of low sodium level in dialysate fluid (sodium profile in advance dialysis machine) is correlates with lower IDWG and Bp. Frequent dialysis session may significant improve of blood pressure control in dialysis patient .The management of BP and volume in dialysis patient requires individual approach to integrate of many clinical and diagnostic therapy and patients’ factors.
Hypertension comes in different forms, different reason for each type .to get proper treatment for your condition you should be familiar with type of hypertension you have it. In CKD patient, may high blood pressure first sign of dysfunction and accurate hypertensive management can lead to reduce cardiovascular and kidney complications. antihypertensive drugs treatment of
ACE inhibitors or angiotension receptor blockers, restriction of salty food and proper treatment of diuretics are essential management of hypertensive in patient with chronic kidney disease. In dialysis patient, frequent dialysis session, control volume overload,UF rate monitoring blood pressure (pre and post dialysis ) and low sodium level in dialysate, are important factors to manage and control blood pressure . The lack of commitment to antihypertensive drugs, one of the main reasons for uncontrolled blood pressure in CKD patient.
Reference:
Kidney Disease Improving Global outcomes (KDIGO)
Kidney international org.
Fifth edition dialysis Jonn T. Peter G. Todd S.
