Does Chronic Kidney Disease (CKD) cause Hypertension (HTN)?

From the Guidelines

No, Chronic Kidney Disease (CKD) does not cause Hypertension (HTN), but rather, HTN is a major risk factor for the development and progression of CKD 1.

Key Points

• Hypertension is a significant risk factor for CKD, and CKD is associated with a high risk of cardiovascular disease (CVD) 1
• The relationship between CKD and HTN is complex, with HTN contributing to the development and progression of CKD, and CKD increasing the risk of resistant hypertension, masked hypertension, and elevated nighttime BP values 1
• Treatment of hypertension is crucial for reducing CVD risk in CKD and slowing the progression of CKD 1
• Blood pressure targets in CKD are debated, with some guidelines recommending a target systolic blood pressure of <120 mm Hg 1, while others suggest a target of <130/80 mm Hg 1
• Medications such as RAS-inhibitors, CCBs, and diuretics are commonly used to treat hypertension in CKD, with monitoring of eGFR, microalbuminuria, and blood electrolytes recommended 1

Important Considerations

• CKD is an important risk factor for CVD, and the coexistence of hypertension and CKD further increases the risk of adverse CVD and cerebrovascular events 1
• Patients with CKD were historically excluded from clinical trials, limiting the data supporting BP targets in CKD 1

From the Research

Relationship Between CKD and Hypertension

• Chronic Kidney Disease (CKD) and Hypertension (HTN) are closely related, with long-term HTN leading to poor kidney function and renal function decline leading to worsening blood pressure control 2, 3.
• The interplay of factors contributing to HTN in CKD includes salt and water retention, sympathetic nervous system overactivity, renin-angiotensin-aldosterone system activation, and endothelial dysfunction 2, 3.

CKD as a Cause of Hypertension

• Current evidence supports the notion that CKD is a cause of chronic hypertension, even in the absence of detectable changes in glomerular filtration rate 4.
• Proteinuria may mediate sodium retention and hypertension via plasmin-mediated activation of the epithelial sodium channel, contributing to the development of HTN in CKD 4.

Hypertension and Kidney Disease Progression

• Hypertension is associated with kidney disease progression, and hypertensive nephropathy is a diagnosis that defines many cases of CKD of unknown etiology 5.
• The risk of progression of hypertension-attributed nephropathy may have a genetic background, as demonstrated in African-American patients with APOL1 gene risk variants 5.

Management of Hypertension in CKD

• Hypertension in CKD is often accompanied by a decrease in the kidney's ability to remove salt, making salt restriction critical for management 6.
• Addressing salt sensitivity, using ACEI or angiotensin receptor blockers, dietary salt restriction, and appropriate diuretic therapy are key strategies for managing HTN in CKD 6.