1. HYPERTENSION
Kidney Diseases and Blood Pressure
Mohammad Ilyas, M.D.
Assistant Clinical Professor
University of Florida / Health Sciences Center
Jacksonville, Florida USA
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7/2/2014

2. Outline
1. Definition, Regulation and Pathophysiology
2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory
Blood Pressure Monitoring
3. Evaluation of Primary Versus Secondary
4. Sequel of Hypertension and Hypertension Emergencies
5. Management of Hypertension (Non-Pharmacology versus Drug Therapy)
6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep
Disorders.
7. Hypertension in Renal diseases and Pregnancies
8. Pediatric, Neonatal and Genetic Hypertension
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3. Kidney and blood pressure
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4. Kidney Diseases and Blood Pressure
Definition and epidemiology
Prevalence of HTN with CKD
Pathogenesis
Risk factors for progression
Therapy of HTN with CKD
HTN with ESRD
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5. What proportion of adult population
has CKD ?
1. One in four
2. One in eight
3. One in ten
4. One in twenty
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6. What proportion of adult population
has CKD ?
1. One in four
2. One in eight
3. One in ten
4. One in twenty
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7. INTRODUCTION
 CKD = GFR < 60 mL/min/m2
 24.5 % of 60 years and older
has CKD -2006.
 13.1% (1/8) of adult USA
population has CKD
 27 Millions
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8. How does high blood pressure affect the
kidneys?
• High blood pressure can damage blood vessels
by causing scaring and weaken the vessel wall.
• It decrease the GFR  fluid retention 
hypertension  renal damage
• 2nd leading cause of renal failure
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9. Causes of kidney failure in the United
States
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10. Stages of CKD
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Stage GFR* Description
1 90+ Normal kidney function but urine findings or
structural abnormalities or genetic trait point to
kidney disease
2 60-89 Mildly reduced kidney function, and other
findings (as for stage 1) point to kidney disease
3A
3B
45-59
30-44
Moderately reduced kidney function
4 15-29 Severely reduced kidney function
5 <15 or on
dialysis
Very severe, or end stage kidney failure

11. The primary cause of death in CKD is?
A. Infection
B. Cardio Vascular Disease
C. Kidney failure
D. Malignancies
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12. The primary cause of death in CKD is?
A. Infection
B. Cardio Vascular Disease
C. Kidney failure
D. Malignancies
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13. Why CKD Patient have CVD?
30-50% INFLAMATION (increased CRP, increase IL-6,
decrease albumin)
CRP is a marker for CVD
CKD have metastatic calcification (increase PTHi,
Ca, PO4 level)
 Hyperlipidemia
 Hypertension
 Anemia
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14. Hypertension in CKD
23.3% of individuals without CKD, and
35.8% of stage 1,
48.1% of stage 2,
59.9% of stage 3, and
84.1% of stage 4-5 CKD patients
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15. PATHOGENESIS
The pathogenesis of hypertension varies with the
type of disease
Glomerular versus Vascular
&
Acute versus Chronic
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16. Acute glomerular disease
Acute glomerular disease, (e.g.
poststreptococcal glomerulonephritis)
Increase Blood pressure is primarily due to fluid
overload (as evidenced by suppression of the RAAS
and enhanced release of atrial natriuretic peptide)
Fluid overload is due to Na retention, Na+ retention is
due to increased reabsorption in the collecting
tubules.
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17. Acute glomerular disease
Two different abnormalities in collecting tubule
function have been identified in glomerular disease,
both of which could increase sodium reabsorption:
Relative resistance to Atrial Natriuretic Peptide, (ANP)
due at least in part to more rapid degradation of the
second messenger cyclic GMP by the enzyme
phosphodiesterase .
Increased activity of the Na-K-ATPase pump in the
cortical collecting tubule but not other nephron
segments . This pump provides the energy for active
sodium transport by pumping reabsorbed sodium out
the cell into the peritubular capillary.
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18. Acute vascular disease
 Hypertension is also common in acute vascular diseases,
such as vasculitis or scleroderma renal crisis.
 In these settings, the elevation in blood pressure results
from ischemia-induced activation of the renin-
angiotensin system rather than volume expansion
 This difference in mechanism between glomerular and
vascular disease may be of therapeutic importance
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19. PATHOGENESIS
1. Sodium and volume excess due to diminished
sodium excretory capacity.
2. Activation of the renin-angiotensin-aldosterone
system due to primary vascular disease or to
regional ischemia induced by scarring.
3. Increased activity of the sympathetic nervous
system.
4. An increase in endothelium-derived
vasoconstrictors (such as endothelin)
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20. PATHOGENESIS
5. A reduction in endothelium-derived
vasodilators (such as nitric oxide).
6. The administration of erythropoietin (EPO).
7. An increase in intracellular calcium induced by
PTH excess.
8. Calcification of the arterial tree.
9. Preexistent primary hypertension.
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21. Angiotensin and CKD
Angiotensin, which is a protein, is a component of
the renin-angiotensin-aldosterone system (RAAS),
which performs important functions in the
regulation of fluid balance and blood pressure in
the human body.
It has two forms:
Angiotensin I (AI) and Angiotensin II (AG II).
Generally, the function of angiotensin is to raise
the blood pressure. 7/2/2014
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22. 7/2/2014
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23. 7/2/2014
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24. Addition to the factors
Patients with end-stage renal disease are more
likely to have an increase in central pulse
pressure and isolated systolic hypertension.
Patients with chronic kidney disease may not
demonstrate the normal nocturnal decline in
blood pressure (such patients are called
"nondippers"),
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25. TREATMENT OF HTN IN CKD
Treatment of even mild hypertension is
important in patients with chronic kidney
disease (CKD) to protect against both
1. Progressive renal function loss and
2. Cardiovascular disease, the incidence of
which is increased with mild to moderate
CKD
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26. Goal of BP when treating a patient
with proteinuria is?
A.< 160/100
B.< 140/90
C.< 130/80
D.< 115/70
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27. Goal of BP when treating a patient
with proteinuria is?
A.< 160/100
B.< 140/90
C.< 130/80
D.< 115/70
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28. Goal blood pressure
 Management of blood pressure in chronic kidney
disease that goal blood pressure depends upon the
degree of proteinuria:
 Proteinuric CKD, (500 mg/day or higher),
the BP < 130/80 mmHg.
 Nonproteinuric CKD, (<500 mg/day),
the BP < 140/90 mmHg.
 Isolated systolic HTN, systolic pressure <150 mmHg
 Proteinuria goal of less than 1000 mg/day
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29. BP measurement in CKD
 24-hour ambulatory blood pressure is a stronger
predictor of end-stage renal disease (ESRD),
cardiovascular disease, and death than office-based
measurements
 A daytime ambulatory systolic pressure greater than 145
mmHg was associated with a threefold increased risk of
developing cardiovascular disease and a nearly twofold
increased risk of ESRD or death compared with patients
whose daytime systolic pressure was 126 to 135 mmHg.
 The prognostic value of nighttime ambulatory blood
pressure was even stronger
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30. Management
1. Sodium restriction
2. Diuretics
1. Thiazide diuretics become less effective when the GFR is less than 30
mL/min
2. Loop diuretics are preferred as initial therapy
3. Antihypertensive therapy in proteinuric CKD
1. angiotensin inhibitors as first-line therapy
2. CCB and diuretic with ACE or ARB
4. Antihypertensive therapy in non-proteinuric CKD
1. with edema, initial therapy with a loop diuretic
2. without edema, an ACE, and then add a dihydropyridine CCB
5. Benefit from nocturnal therapy 7/2/2014
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31. Hypertension in ESRD
There are several major issues to consider when
approaching hypertension in dialysis patients
1.What is the pathogenesis of the elevation in
blood pressure (BP)?
2.How is hypertension best defined?
3.What are the target BP goals?
4.How should the hypertension be treated?
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32. Hypertension and ESRD
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33. Hypertension in ESRD
 Over 50 to 60 percent of hemodialysis
 Nearly 30 percent of peritoneal dialysis patients are
hypertensive
 Volume overload
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34. Quiz
Test your knowledge
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35. Quiz 1. Goal of BP when treating a
patient with proteinuria is?
A.< 160/100
B.< 140/90
C.< 130/80
D.< 115/70
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36. Quiz 1. Goal of BP when treating a
patient with proteinuria is?
A.< 160/100
B.< 140/90
C.< 130/80
D.< 115/70
7/2/2014
36

37. Quiz 2. What proportion of adult
population has CKD ?
1. One in four
2. One in eight
3. One in ten
4. One in twenty
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38. Quiz 2. What proportion of adult
population has CKD ?
1. One in four
2. One in eight
3. One in ten
4. One in twenty
7/2/2014
38

39. Quiz 3. The primary cause of death in
CKD is?
A. Infection
B. Cardio Vascular Disease
C. Kidney failure
D. Malignancies
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40. Quiz 3. The primary cause of death in
CKD is?
A. Infection
B. Cardio Vascular Disease
C. Kidney failure
D. Malignancies
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41. Quiz 4. The pathogenesis of hypertension in
glomerular disease includes all EXCEPT?
A. Increase Blood pressure is primarily due to fluid
overload.
B. Fluid overload is due to Na retention
C. Relative resistance to atrial natriuretic peptide
D. Increased activity of the Na-K-ATPase pump
E. Blood pressure results from ischemia-induced activation
of the renin-angiotensin system
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42. Quiz 4. The pathogenesis of hypertension in
glomerular disease includes all EXCEPT?
A. Increase Blood pressure is primarily due to fluid
overload.
B. Fluid overload is due to Na retention
C. Relative resistance to atrial natriuretic peptide
D. Increased activity of the Na-K-ATPase pump
E. Blood pressure results from ischemia-induced activation
of the renin-angiotensin system
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