Term
| What are the causes of HTN? |
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Definition
Primary - Essential HTN
Secondary - CKD, Coarctation of the aorta |
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Term
| What are some contributing factors to HTN in CKD? |
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Definition
- Sodium and Volume
- Increased vasoconstrictor activity
- Decreased vasodilator activity
- EPO use
- PTH and Ca
- Structure changes in arteries
- Primary HTN
- Renovascular Dz
- Others...... |
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Term
| What causes resistant HTN? |
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Definition
- Improper measurement of BP
- Fluid overload due to non-adherence of fluid restriction or dialysis regimen
- Medication-related (sub therapeutic, wrong-med, side effect)
- Obesity and excess EtOH intake |
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Term
| What medications could be held responsible for inducing HTN? |
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Definition
- NSAIDS
- Corticosteroids
- Calcineurin inhibitors - transplant medications (cyclosporin)
- Sympathomimetics
- ESA's
- Oral Contraceptives
- Ilicit drugs like cocaine or amphetamines (maybe crystal meth?)
- Certain herbal/supplements |
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Term
| What are the JNC7 Guidelines? |
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Definition
- PreHTN, Stage I, Stage II
- Goal BP is <140/90 or <130/80
- Treatment 1st line, compelling indications |
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Term
| What are the compelling indications and corresponding drug classes for JNC7? |
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Definition
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Compelling Indication
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Preferred 1st Line Agents
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Heart failure
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THIAZ, BB, ACEI, ARB, ALDO ANT
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Post myocardial infarction
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BB, ACEI, ALDO ANT
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High CVD risk
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THIAZ, BB, ACEI, CCB
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Diabetes
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THIAZ, BB, ACEI, ARB, CCB
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Chronic kidney disease
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ACEI, ARB
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Recurrent stroke prevention
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THIAZ, ACEI
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Term
| To quickly review.....what are the BP goals and first line agents in a CKD patient? |
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Definition
BP Goal < 130/80mmHg
First line: ACEi or ARB |
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Term
| In stages 1-5 of CKD, what are the guidelines of treatment as set forth by JNC7? |
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Definition
Goals of Tx: Dec. BP, Prevent Progression of CKD, Prevent CV events
BP Goals - 130/80 mmHg
Non-pharmacological interventions
First line: ACEi or ARB if DM or proteinuria plus a diuretic in most |
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Term
| What are the treatment goals at stage 5D of CKD? |
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Definition
BP Goal: Go as low as you can go before patient becomes hypotensive
Dialysis: PreHD 140/90
Post HD 130/80
Non-Pharmacological: Fluid management, sodium restriction
First line agents: ACEi/ARBs despite little/no kidney to preserve, still have CV protective effects, cardiac remodeling, regression of LVH |
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Term
| What is the 2009 approach to CKD HTN? |
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Definition
¨Stage I HTN
1.Lifestyle
2.Add 1 drug (ACEi, ARB, CCB, Diuretic)
3.Add 2nd drug (ACEi, ARB, BB, CCB, Diuretic)
4.Add 3rd drug (Adherence; Optimize doses)
¨Stage II HTN
1.Lifestyle + 2 Drugs
2.3rd drug, (Adherence, optimize)
3.4th drug (Address EtOH and salt)
4.Look for 2ndary causes
For one more additional compelling indication, give a BB, or CCB for angina pectoris |
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Term
| What is important regarding thiazide diuretics? |
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Definition
- Offer CV protection
- Used if GFR >30ml/min
- May be used to enhance fluid removal with loop diuretics
- Dose in the AM
- exacerbate gout, hyperglycemia/DM
Loops: Furosemide, Bumetanide, Torsemide; primarily used for fluid management, high doses usually in later stages of CKD, used as adjunctive agents or in treatment of hyperkalemia |
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Term
| What are some things to consider in Dialysis? |
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Definition
- Removal of drugs
- Intradialytic Hypotension
- EDW
- "Non-dipping"
- Timing of medications around dialysis |
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Term
| What are some considerations in the Dialysis removal of drugs? |
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Definition
- Molecular weight/size
- Protein binding
- VD
- Water Solubility
- Plasma Clearance
- Dialysis membrane
- Blood and Dialysate flow rates
- Several BP medications can be removed by HD
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Term
| What's the deal with intradialytic hypotension? |
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Definition
Non-pharmacological
- Adherence with fluid restriction, Sodium/UF profiling, Extended dialysis sessions
Pharmacologic Approaches
- Midodrine, Carnitine, Sertaline |
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Term
| What is non-dipping in Dialysis? |
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Definition
| Non-dipping - Typically patients will have a lower blood pressure at night. CKD patients do not do this and it is a major risk for Cardiovascular events. |
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Term
| How do we time medications around Dialysis? |
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Definition
- Evening preferred for most antihypertensives
- If hypotensive during HD: Hold meds prior, more info to come (Dr. Mason in next lecture or so?)
- If on Diuretics dose in AM if possible
- Very confusing scheduling |
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Term
| What is special about Transplant patients? |
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Definition
- Usually on corticosteroids with Calcineurin inhibitors, will raise BP
- Goal BP is 130/80
- KDOQI recommended agents: CCB, Diuretic, ACEi, ARB, BB
- In terms of Graft loss and transplant kidney function, CCB's were best when treating HTN.
- More studies are needed
- ACE/ARB used in proteinuria
- Other agents could be necessary to control BP
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Term
| What are the key points to remember in CKD patients with HTN? |
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Definition
Hypertension…
¨Is common among those with CKD
¨Increases risk of CV events
¨ACE/ARB Inhibitors are cornerstone therapies for patients with CKD (esp DM / proteinuria)
¨Fluid/Sodium management is imperative in patients with CKD.
¨Methods to improve adherence should be implemented by all clinicians. |
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