What are the effects of Stage 4 Chronic Kidney Disease (CKD) and uncontrolled Hypertension (High Blood Pressure)?

From the Guidelines

Stage 4 Chronic Kidney Disease (CKD) with uncontrolled hypertension is a life-threatening condition that requires immediate attention, as it can lead to accelerated kidney damage, increased cardiovascular risk, and decreased quality of life. The effects of Stage 4 CKD and uncontrolled hypertension are multifaceted, including:

• Accelerated kidney damage and progression to kidney failure
• Increased risk of cardiovascular events, such as heart attack and stroke
• Electrolyte imbalances, fluid retention, and waste buildup
• Anemia, bone disease, and metabolic acidosis According to the 2020 international society of hypertension global hypertension practice guidelines 1, blood pressure should be lowered to a target <130/80 mm Hg (<140/80 in elderly patients) to slow the progression of kidney disease and reduce cardiovascular risk. The guidelines also recommend the use of RAS-inhibitors as first-line drugs, as they reduce albuminuria in addition to blood pressure control. Key aspects of management include:
• Medications: ACE inhibitors or ARBs, diuretics (such as loop-diuretics if eGFR <30 ml/min/1.73m²)
• Dietary changes: sodium restriction, potassium and phosphorus limitation, protein moderation
• Regular monitoring: kidney function, blood pressure, and electrolytes The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1 also supports the importance of blood pressure control in patients with CKD, and recommends a blood pressure target of <130/80 mmHg. Overall, the management of Stage 4 CKD with uncontrolled hypertension requires a comprehensive approach that includes medication, lifestyle modifications, and regular monitoring to slow disease progression and reduce cardiovascular risk.

From the FDA Drug Label

High Blood Pressure (hypertension) Blood pressure is the force in your blood vessels when your heart beats and when your heart rests. You have high blood pressure when the force is too much. For people who already have kidney problems, you may see a worsening in how well your kidneys work. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, post-myocardial infarction or volume depletion) may be at particular risk of developing acute renal failure

The effects of Stage 4 Chronic Kidney Disease (CKD) and uncontrolled Hypertension (High Blood Pressure) include:

• Worsening of kidney function
• Acute renal failure
• Increased risk of hyperkalemia
• Increased risk of cardiac problems, such as left ventricular hypertrophy
• Potential for anaphylactoid reactions and angioedema in some patients 23 It is essential to monitor renal function, blood pressure, and electrolytes in patients with CKD and hypertension, especially when using medications that affect the renin-angiotensin system 2

From the Research

Effects of Stage 4 Chronic Kidney Disease (CKD) and Uncontrolled Hypertension

• Stage 4 CKD and uncontrolled hypertension can lead to severe cardiovascular and cerebrovascular complications, including intracerebral hemorrhage and fits, as seen in a case study of a 25-year-old patient with end-stage renal disease (ESRD) 4.
• The prevalence of hypertension rises significantly as renal function declines, and even mild CKD increases mortality risk, with cardiovascular disease being the main cause of death among these patients 5.
• Uncontrolled hypertension in CKD patients can lead to accelerated progression of renal disease and increased cardiovascular risk, emphasizing the importance of blood pressure control in these patients 5, 6.

Blood Pressure Targets in CKD Patients

• A blood pressure target of less than 140/90 mmHg is considered reasonable for patients with CKD stage III and IV, although some studies suggest that a lower target systolic blood pressure of 120-130 mmHg and diastolic blood pressure of 70-80 mmHg may be beneficial in patients with proteinuria 6.
• The use of angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) is recommended as first-line therapy in hypertensive patients with CKD and proteinuria, but their prescription rates are often lower than recommended, particularly in younger patients 7.

Resistant and Apparent Resistant Hypertension in CKD Patients

• Resistant hypertension is common in CKD patients, and its definition and management may differ from those in the general population, with a need for individualized approaches to blood pressure control 8.
• Apparent treatment-resistant hypertension (ATRH) is defined as uncontrolled blood pressure on three or more antihypertensive medication classes or the introduction and use of four or more medications, regardless of blood pressure level, and its prevalence and management in peritoneal dialysis patients require further study 8.