What is the best course of action for an 80-year-old female patient with acute/chronic renal failure, stage 5 chronic kidney disease (CKD 5), and hypertension, currently being treated with hydralazine (Hydralazine) and clonidine (Clonidine), whose blood pressure remains elevated at 196/77 mmHg despite medication?

From the Guidelines

I strongly recommend contacting the physician immediately to report the patient's persistently elevated blood pressure despite medication administration. The patient's blood pressure remains dangerously high at 196/77 despite receiving IV hydralazine, oral hydralazine 100 mg, and clonidine 0.1 mg. This level of hypertension in an 80-year-old patient with acute/chronic renal failure and CKD stage 5 requires urgent medical attention.

When calling the physician, provide the complete blood pressure trend, medication administration times, and note that the patient is currently asymptomatic. Ask for additional medication orders or possible transfer to a higher level of care if appropriate. While waiting for the physician's response, continue to monitor the patient's vital signs every 15-30 minutes, assess for any new symptoms like headache, vision changes, chest pain, or neurological deficits, and keep the head of the bed elevated.

The patient's kidney disease likely contributes to difficult-to-control hypertension due to fluid overload, electrolyte imbalances, and an overactive renin-angiotensin-aldosterone system. The current medication regimen is proving insufficient, and the physician may need to add additional antihypertensive agents or adjust the current dosing schedule. According to 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, the patient's blood pressure goal should be less than 130/80 mm Hg.

Some potential additional treatment options for this patient could include:

• Adding a diuretic, such as furosemide or torsemide, to help manage fluid overload and reduce blood pressure 1
• Adding a beta-blocker, such as metoprolol or carvedilol, to help reduce blood pressure and slow heart rate 1
• Adding an aldosterone antagonist, such as spironolactone or eplerenone, to help reduce blood pressure and manage electrolyte imbalances 1

This level of hypertension puts the patient at risk for hypertensive emergency, including stroke, myocardial infarction, or further kidney damage. Therefore, it is essential to prioritize the patient's safety and take immediate action to reduce their blood pressure.

From the FDA Drug Label

In hypertensive patients with normal kidneys who are treated with hydrALAZINE, there is evidence of increased renal blood flow and a maintenance of glomerular filtration rate. In some instances where control values were below normal, improved renal function has been noted after administration of hydrALAZINE However, as with any antihypertensive agent, hydrALAZINE should be used with caution in patients with advanced renal damage. The patient has acute/chronic renal failure, CKD 5, and is being treated with hydralazine. The drug label states that hydralazine should be used with caution in patients with advanced renal damage. Given the patient's condition, it is essential to monitor their renal function closely while on hydralazine therapy.

• The patient's blood pressure is still high after administration of hydralazine and clonidine.
• The patient denies any dizziness or symptoms.
• The use of hydralazine in patients with advanced renal damage requires careful consideration of the potential risks and benefits.
• The patient's renal function should be closely monitored while on hydralazine therapy 2.

From the Research

Patient's Condition

The patient is an 80-year-old female with a diagnosis of acute/chronic renal failure and CKD 5, presenting with high blood pressure.

Blood Pressure Management

• The patient's blood pressure has been high, with readings of 193/80,187/72, and 196/77, despite administration of iv hydralazine and scheduled medications including hydralazine 100 mg po and clonidine 0.1 mg 3.
• According to a study published in the Annals of Emergency Medicine, patients with severely elevated blood pressure should be evaluated for acute target organ damage and have their medical regimen adjusted 3.
• Another study published in the Journal of the American College of Cardiology suggests that angiotensin receptor blockers (ARBs) may be a better option than angiotensin-converting enzyme (ACE) inhibitors for hypertension due to their equal efficacy and fewer adverse events 4.
• A Cochrane review comparing ACE inhibitors and ARBs for primary hypertension found no difference in total mortality or cardiovascular outcomes, but ARBs caused slightly fewer withdrawals due to adverse effects 5.
• A study published in the American Journal of Hypertension found that diuretics and calcium-blocking drugs are more effective in elderly patients at lowering systolic blood pressure, while beta-blockers were relatively ineffective and had more side effects 6.

Current Guidelines

• The American Heart Association has published a scientific statement on the management of elevated blood pressure in the acute care setting, highlighting the lack of evidence guiding management in this setting and the need for further research 7.
• The statement suggests that hypertensive emergency should be treated swiftly with intravenous antihypertensive medications, but the risk-benefit ratio of initiating or intensifying antihypertensive medications for asymptomatic elevated inpatient BP is less clear 7.