Resistant Hypertension in People With CKD: A Review

Management of Patients With Kidney Disease Undergoing Bariatric Surgery: A Multidisciplinary Approach

Bariatric surgery is increasingly recognized as a safe and effective treatment for obesity in patients with chronic kidney disease (CKD), including stages 4, 5, and 5D (on dialysis). Among the available surgical methods, sleeve gastrectomy (SG) is the most commonly performed weight loss procedure and is mainly done to facilitate kidney transplantation (KT). However, many KT candidates treated with SG remain on the transplant waiting list for months to years, with some never receiving a transplant. Therefore, appropriate candidates for SG must be selected, and post-SG management should address the unique needs of this population, with a focus on sustaining the metabolic benefits of surgery while minimizing potential side effects related to rapid weight loss which may inadvertently lead to muscle and bone catabolism. Multidisciplinary post-SG care in this population may lead to overall better health on the transplant waiting list, resulting in a higher percentage of post-SG patients ultimately receiving KT. To tailor the effective treatment for these patients, clinicians should acknowledge that patients with CKD stage 4-5D have different nutritional needs and are metabolically and psychosocially distinct from the general bariatric surgery population. Sarcopenia is highly prevalent and may be exacerbated by muscle catabolism following SG if not adequately addressed. Blood pressure, glucose, and bone metabolism are all affected by the CKD stage 4-5D, and therefore require distinct diagnostic and management approaches. Long-standing chronic disease, associated comorbidities, and low adherence to medical therapies require ongoing comprehensive psychosocial assessment and support. This paper aims to review and consolidate the existing literature concerning the intersection of CKD stage 4-5D and the consequences of SG. We also suggest future clinical outcome studies examining novel treatment approaches for this medically complex population.

Unique characteristics of Asians with hypertension: what is known and what can be done?

Hypertension remains the leading modifiable risk factor for cardiovascular disease worldwide. Over the past 30 years, the prevalence of hypertension has been increasing in East and Southeast Asia to a greater extent as compared with other Western countries. Asians with hypertension have unique characteristics. This can be attributed to increased impact of obesity on Asians with hypertension, excessive salt intake and increased salt sensitivity, loss of diurnal rhythm in blood pressure and primary aldosteronism. The impact of hypertension on cardiovascular (particularly strokes) and chronic kidney disease is greater in Asians. These unique characteristics underpinned by the diverse socioeconomic backgrounds pose its own challenges in the diagnosis and management of hypertension in Asia.

Controversies in Hypertension V: Resistant and Refractory Hypertension

Apparent resistant hypertension, defined as uncontrolled office blood pressure despite ≥ 3 antihypertensive medications including a diuretic or use of ≥ 4 medications regardless of blood pressure, occurs in ≤ 15% of treated hypertensives. Apparent refractory hypertension, defined as uncontrolled office pressure despite use of 5 or more medications including a diuretic, occurs in ≤ 10% of resistant cases. Both are associated with increased comorbidity and enhanced cardiovascular risk. To rule out pseudo-resistant or pseudo-refractory hypertension, employ guideline-based methodology for obtaining pressure, maximize the regimen, rule out white-coat effect, and assess adherence. True resistant hypertension is characterized by volume overload and aldosterone excess, refractory by enhanced sympathetic tone. Spironolactone is the preferred agent for resistance, with lower doses. Spironolactone, potassium binders, or both, are preferred if the estimated glomerular filtration rate is below 45. If significant albuminuria, finerenone is indicated. The optimal treatment of refractory hypertension is unclear, but sympathetic inhibition (α-β blockade, centrally acting sympathoinhibitors, or both) seems reasonable. Renal denervation has shown minimal benefit for resistance, but its role in refractory hypertension remains to be defined.

Renal Denervation in the Treatment of Resistant Hypertension and Difficult-to-Control Hypertension - Consensus Document of the Croatian Hypertension League - Croatian Society of Hypertension, Croatian Cardiac Society, Croatian Endovascular Initiative, Croatian Society for Diabetes and Metabolic Diseases, Croatian Renal Association, and Croatian Society of Family Physicians of the Croatian Medical Association

Renal denervation (RDN) as a method of treating arterial hypertension (AH) was introduced in Croatia in 2012. A multidisciplinary team and a network of hospitals that diagnose and treat patients with severe forms of AH were established, and a very strict diagnostic-treatment algorithm was prepared. At monthly meetings patients with truly resistant hypertension who were candidates for RDN were discussed. According to the 2021 ESH position statement and 2023 ESH guidelines, RDN is considered an alternative and additional, not a competitive method of treating patients with various forms of AH which must be performed by following a structured procedure and the patient's preference should be considered. In view of the changes in the global scientific community, the Croatian Hypertension League brings this consensus document on RDN conducted with radiofrequency-based catheter, the only currently available method in Croatia. In this document, exclusion and inclusion criteria are shown, as well as three groups of patients in whom RDN could be considered. The new diagnostic-treatment algorithm is prepared and follow-up procedure is explained. In Croatia, RDN is reimbursed by the national insurance company, thus pharmacoeconomic analyses is also shown. Criteria required by an individual centre to be approved of RDN are listed, and plans for prospective research on RDN in Croatia, including the Croatian registry for RDN, are discussed.

New Potential Treatments for Resistant Hypertension

PURPOSE OF REVIEW

To provide an update and review approaches to the treatment of resistant hypertension (RH) with a focus on emerging potential therapies.

RECENT FINDINGS

Resistant hypertension is defined as a blood pressure that remains elevated above a patient's individualized target despite the concurrent use of 3 antihypertensive agents of different classes including a diuretic or use of 4 or more antihypertensive agents. Patients with RH have an increased risk of adverse cardiovascular and renal outcomes. Most RH is attributed to apparent RH and is not true RH. True RH is a diagnosis of exclusion after apparent RH has been excluded. Treatment of RH is challenging, and blood pressure goal is often difficult to achieve. Currently several new therapies have emerged with forthcoming data that provide promise for improved blood pressure control in those with resistant hypertension. Once RH has been diagnosed, patients should be on standardized therapy that includes agents from three different classes including a diuretic with addition in most cases of a mineralocorticoid as a fourth line agent. There are newer agents in development currently being studied in clinical trials including dual endothelin receptor antagonists and aldosterone synthase inhibitors that appear to be efficacious. Other approved medications including SGLT2 inhibitors and non-steroidal mineralocorticoids such as finerenone also need to be incorporated into treatment paradigms. Renal denervation with catheter based devices is another potential promising treatment option in this population.

Does Renal Denervation a Reasonable Treatment Option in Hemodialysis-Dependent Patient with Resistant Hypertension? A Narrative Review

PURPOSE OF REVIEW

This narrative review aims to assess the pathophysiology, diagnosis, and treatment of resistant hypertension (RH) in end-stage kidney disease (ESKD) patients on dialysis, with a specific focus on the effect of renal denervation (RDN) on short-term and long-term blood pressure (BP) control. Additionally, we share our experience with the use of RDN in an amyloidotic patient undergoing hemodialysis with RH.

RECENT FINDINGS

High BP, an important modifiable cardiovascular risk factor, is often observed in patients in ESKD, despite the administration of multiple antihypertensive medications. However, in clinical practice, it remains challenging to identify RH patients on dialysis treatment because of the absence of specific definition for RH in this context. Moreover, the use of invasive approaches, such as RDN, to treat RH is limited by the exclusion of patients with reduced renal function (eGFR < 45 mL/min/1.73 m3) in the clinical trials. Nevertheless, recent studies have reported encouraging results regarding the effectiveness of RDN in stage 3 and 4 chronic kidney disease (CKD) and ESKD patients on dialysis, with reductions in BP of nearly up to 10 mmhg. Although multiple underlying pathophysiological mechanisms contribute to RH, the overactivation of the sympathetic nervous system in ESKD patients on dialysis plays a crucial role. The diagnosis of RH requires both confirmation of adherence to antihypertensive therapy and the presence of uncontrolled BP values by ambulatory BP monitoring or home BP monitoring. Treatment involves a combination of nonpharmacological approaches (such as dry weight reduction, sodium restriction, dialysate sodium concentration reduction, and exercise) and pharmacological treatments. A promising approach for managing of RH is based on catheter-based RDN, through radiofrequency, ultrasound, or alcohol infusion, directly targeting on sympathetic overactivity.

Resistant hypertension: consensus document from the Korean society of hypertension

Although reports vary, the prevalence of true resistant hypertension and apparent treatment-resistant hypertension (aTRH) has been reported to be 10.3% and 14.7%, respectively. As there is a rapid increase in the prevalence of obesity, chronic kidney disease, and diabetes mellitus, factors that are associated with resistant hypertension, the prevalence of resistant hypertension is expected to rise as well. Frequently, patients with aTRH have pseudoresistant hypertension [aTRH due to white-coat uncontrolled hypertension (WUCH), drug underdosing, poor adherence, and inaccurate office blood pressure (BP) measurements]. As the prevalence of WUCH is high among patients with aTRH, the use of out-of-office BP measurements, both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), is essential to exclude WUCH. Non-adherence is especially problematic, and methods to assess adherence remain limited and often not clinically feasible. Therefore, the use of HBPM and higher utilization of single-pill fixed-dose combination treatments should be emphasized to improve drug adherence. In addition, primary aldosteronism and symptomatic obstructive sleep apnea are quite common in patients with hypertension and more so in patients with resistant hypertension. Screening for these diseases is essential, as the treatment of these secondary causes may help control BP in patients who are otherwise difficult to treat. Finally, a proper drug regimen combined with lifestyle modifications is essential to control BP in these patients.

Monitoring antihypertensive drug concentrations to determine nonadherence in hypertensive patients with or without a kidney transplant

BACKGROUND

Nonadherence to antihypertensive drugs (AHDs) is a major contributor to pseudo-resistant hypertension. The primary objective of this study was to determine the prevalence of nonadherence to AHDs among patients visiting the nephrology and vascular outpatient clinics.

METHODS

Patients were eligible to participate in this prospective observational study if they used at least two AHDs that could be measured with a validated UHPLC-MS/MS method and had an office blood pressure at least 140 and/or at least 90 mmHg. For resistant hypertension, included patients had to use at least three AHDs including a diuretic or four AHDs. Adherence was assessed by measuring drug concentrations in blood. The complete absence of drug in blood was defined as nonadherence. A posthoc analysis was performed to determine the influence of a having a kidney transplant on the adherence rates.

RESULTS

One hundred and forty-two patients were included of whom 66 patients fulfilled the definition of resistant hypertension. The overall adherence rate to AHDs was 78.2% ( n  = 111 patients), with the highest adherence rate for irbesartan (100%, n  = 9) and lowest adherence rate for bumetanide ( n  = 69%, n  = 13). In further analysis, only kidney transplantation could be identified as an important factor for adherence (adjusted odds ratio = 3.35; 95% confidence interval 1.23-9.09). A posthoc analysis showed that patients with a kidney transplant were more likely to be adherent to AHDs (non-KT cohort 64.0% vs. KT-cohort 85.7%, χ 2 (2) = 10.34, P  = 0.006).

CONCLUSION

The adherence rate to AHDs in hypertensive patients was high (78.2%) and even higher after a kidney transplant (85.7%). Furthermore, patients after kidney transplant had a lower risk of being nonadherent to AHDs.

Incidence and Factors Associated with Uncontrolled Hypertension at 12 months after Kidney Transplantation in Saudi Arabia

INTRODUCTION

Uncontrolled blood pressure (uBP) after kidney transplantation (KTx) is very common and is associated with significant morbidity. However, studies that assess its incidence and risk factors are limited and outdated in the Middle East.

METHODS

This is a single-center retrospective study of KTx recipients (KTRs) in our center between January 2017 and May 2020 with a 12-month follow-up period. The target of hypertension treatment during the time of this study was <140/90 mm Hg, according to the published guidelines. We divided patients according to their blood pressure (BP) control at 1 year into two groups: controlled BP (cBP) (<140/90) and uBP (≥140/90). We studied the association between uBP and patients' demographics, baseline cardiovascular risk factors, and changes in their metabolic and cardiovascular profile during the first 12 months post-KTx.

RESULTS

A total of 254 KTRs were included. 79.2% developed post-KTx hypertension, 74% were ≥30 years, 58% were men, and 80% were living donor KTRs. The renal replacement modality among our patients pre-KTx was hemodialysis in 78.4%, peritoneal dialysis in 11.5%, and 10.1% underwent preemptive transplantation. At 1 year, 76 (29.9%) KTRs did not attain the target BP goal. Systolic BP (SBP) decreased from baseline to 12 months by 13 ± 24 mm Hg in the cBP group and increased by 8.7 ± 21 mm Hg in the uBP group (p < 0.001). Additionally, diastolic BP (DBP) decreased by 8.5 ± 16.9 mm Hg in the cBP group and increased by 2.3 ± 18.8 mm Hg in the uBP group (p < 0.001). Factors associated with uBP included age (47 vs. 41 years, p = 0.008) and diabetes mellitus (p = 0.012). Contrarily, gender, dialysis vintage, preemptive transplantation, type of dialysis (hemodialysis vs. peritoneal dialysis), type of transplant (living donor KTx vs. deceased donor KTx), and smoking were not different among the two groups. There were no significant differences between the two groups in regard to changes in creatinine, weight, A1c, low-density lipoprotein, and parathyroid hormone levels. Additionally, rate of rejection, new onset diabetes post-transplant, and persistent hyperthyroidism were not different between the groups. However, higher body mass index at 12 months was associated with a higher incidence of uBP (27.2 ± 5.9 vs. 29.2 ± 5.4, p = 0.013). Using multivariate analysis, we found that serum creatinine at 12 months was the only predictor of uBP (OR = 1.005 [1-1.011], p = 0.036).

CONCLUSION

At 1-year post-renal transplantation, about one-third of KTRs had uBP despite multiple antihypertensive medications. SBP and DBP significantly trended upward after transplantation in uBP patients, whereas SBP and DBP significantly trended downward after transplantation in cBP patients. Serum creatinine at 12 months was the only factor independently associated with uBP.

A Need for Improvement in the Definition of Resistant Arterial Hypertension

With the medical and social importance of resistant arterial hypertension (HTN) in mind, we had three goals in this paper: to study the definitions of resistant HTN in the guidelines on the topic, to analyze them, and to suggest some improvements. We found (at least) eleven insufficiencies in the definition of resistant HTN: (1) different blood pressure (BP) values are used for diagnoses; (2) the number of BP measurements is not specified; (3) the time-frame for the definition is not obtained; (4) it fails to provide normal or target or controlled BP values; (5) secondary HTN is not currently defined as true resistant HTN, but as apparently treatment-resistant HTN; (6) the definition usually directly incorporates BP cut-offs for systolic BP (sBP) and diastolic BP (dBP) making the diagnosis temporary; (7) stress is not included in the exclusion strategy for resistant HTN; (8) there is potentially a need to introduce a category of recovered resistant HTN; (9) to what degree do healthy lifestyle measures have to be fulfilled to consider it as sufficient to change the diagnosis from "apparent treatment-resistant HTN" to the "resistant HTN"; (10) sBP values normal-for-the-age for 61 and 81 year old patients in some guidelines fulfill the criterion for resistant HTN; (11) it probably ought to read "In the absence of contraindications and compelling indications…" in the others. We believe that it is better to use the phrase "above the target BP" for the definition of (treatment) resistant HTN, because the whole story of resistant HTN is related to non-responders to antihypertensive treatment. Therefore, as we treat to target and not to normal values, it is appropriate to define resistant HTN as an insufficiency to reach the target BP values. Moreover, the definition of (treatment) resistant HTN should not be universal for every patient with HTN, but it should be age-related: (treatment) resistant HTN is elevated BP over the target/normal BP values. Using this modification, there will be no need to automatically change the definition of resistant HTN when we change the BP targets in the future.

Gender and socioeconomic disparities in global burden of chronic kidney disease due to glomerulonephritis: A global analysis

AIM

To investigate the gender and socioeconomic disparities in the global burden of chronic kidney disease (CKD) due to glomerulonephritis from 1990 to 2019.

METHODS

Data were extracted from the global burden of diseases (GBD) 2019 study, including incidence, prevalence and disability-adjusted life-years (DALYs). Estimated annual percentage changes (EAPCs) were calculated to quantify the temporal trends in age-standardized rate (ASR) of CKD due to glomerulonephritis. Paired t-test, paired Wilcoxon signed-rank test and Spearman correlation were performed to analyse the association and gender disparity in CKD due to glomerulonephritis.

RESULTS

Globally, incident cases of CKD due to glomerulonephritis increased 81% from 9 557 397 in 1990 to 17 308 071 in 2019. The age-standardized incidence rate increased by 1.47 compared with 1990 and DALYs increased by 1.35 compared with 1990 (per 100 000). The number of patients with CKD due to glomerulonephritis in low-middle SDI (3829917) and middle SDI (6268817) regions accounts for more than 55% of the total cases. CKD due to glomerulonephritis caused a higher burden including the incidence rate (p < .0001) and DALY rate (p < .0001) in men compared to women. The age-standardized DALY rate was negatively correlated with SDI (ρ = -0.64, p < .001). In the analysis of risk factors for DALYs, male individuals had a larger burden of hypertension, high BMI and high sodium diet in the DALY rates than female subjects.

CONCLUSION

The burden of CKD due to glomerulonephritis was more skewed towards developing and less developed economies and differed by gender, so certain nations should implement far more focused and targeted policies.

Associated factors and hemodynamic characteristics of resistant hypertension in the elderly

The purpose of this study was to explore the associated factors and hemodynamic characteristics of resistant hypertension (RHTN) in the elderly. A total of 283 patients aged ≥60 years with hypertension were evaluated by the CNAP™ monitor. Among them, 240 patients were non-RHTN (controlled hypertension with use of three or fewer antihypertensive medications) and 43 patients were RHTN (uncontrolled hypertension despite the concurrent use of ≥3 antihypertensive drugs at optimized doses, including a diuretic, or achieving target blood pressure with the use of ≥4 antihypertensive medications). RHTN was associated with higher body mass index (BMI), longer hypertension duration, and coronary heart disease (p = .004, p < .001, and p = .042, respectively). The mean number of antihypertensive medications was greater in patients with RHTN (p < .001). Hemodynamic analysis revealed higher cardiac output in the RHTN group than in the non-RHTN group, while no difference was observed in systemic vascular resistance. Screening for secondary etiology showed that, among the 43 patients with RHTN, 8 (18.6%) had chronic kidney disease, 8 (18.6%) had obstructive sleep apnea, 4 (9.3%) had primary aldosteronism, 2 (4.7%) had renovascular disease. No significant differences were observed in the cardiac output and systemic vascular resistance values between different causes of RHTN. These findings suggest that higher body mass index, longer hypertension duration, and coronary heart disease emerged as the associated factors of RHTN in the elderly. RHTN is characterized by higher cardiac output. Screening for the possible secondary etiology of RHTN in the elderly patients is necessary and important.

Hypertension in Chronic Kidney Disease: An Update on Diagnosis and Management

Hypertension (HTN) and chronic kidney disease (CKD) are pathophysiologic states that are intimately related, such that long-term HTN can lead to poor kidney function, and renal function decline can lead to worsening blood pressure (BP) control. HTN in CKD is caused by an interplay of factors, including salt and water retention, with extracellular volume expansion, sympathetic nervous system overactivity, renin-angiotensin-aldosterone system activation, and endothelial dysfunction. BP variability in the CKD population is significant, however, and thus requires close monitoring for appropriate management. With accumulating evidence, the diagnosis as well as management of HTN in CKD has been evolving in the last decade. In this comprehensive review based on current evidence and recommendations, we summarize the basics of pathophysiology, BP variability, diagnosis, and management of HTN in CKD with an emphasis on special populations with CKD.

A Design-assisted Spectrofluorometric Method Utilizing a One-pot Fluorescent Probe for the Quantitation of some Calcium Channel Blockers

Based on their reaction with highly fluorescent carbon quantum dots (CQDts), a precise and reliable spectrofluorometric approach was developed for the determination of three calcium channel blockers. The studied drugs are: lercanidipine, nimodipine and nifedipine. (CQDts) were produced using a one-step hydrothermal method with ascorbic acid as the carbon source. The produced CQDts were capped by alcohol to create yellow emitters displaying a high fluorescence emission at 524 nm when excited at 325 nm. The fluorescence intensity of CQDts was noticeably quenched by each of the three calcium channel blockers. The relation between their concentrations and fluorescence quenching is linear over the concentration range of 0.5-20 µg/mL for each of the three drugs. A full factorial design was used to optimize the effect of variable factors. Therefore, under optimum experimental design conditions, the detection limits for lercanidipine, nimodipine, and nifedipine were 0.11 ± 1.09, 0.10 ± 0.25 and 0.12 ± 0.71 µg/mL, respectively. The LOQ was 0.33, 0.30, and 0.37 µg/mL respectively. The quenching of fluorescent CQDts occurred through the inner filter effect (IFE) for nimodipine, while it was mixed with dynamic quenching for lercanidipine and nifedipine. The proposed method was effectively used to determine the cited drugs in their pharmaceutical products and had an acceptable level of precision. The selectivity of the CQDts system towards the studied drugs was examined indicating no interference from interfering species.

Catheter-based renal denervation in Chinese patients with chronic kidney disease and uncontrolled hypertension

Sympathetic activation contributes to the progression of hypertension and chronic kidney disease (CKD). Ablation of renal sympathetic nerves lowers blood pressure (BP) and preserves renal function in patients with CKD and uncontrolled hypertension by reducing sympathetic nerve activity. But whether this approach is safe and effective in Chinese patients with CKD is unknown. We performed an observational study of eight patients with CKD stages from 1 to 5, office BP ≥150/90 mmHg, while on at least three antihypertensive drug classes including a diuretic, and diagnosis confirmed by 24 h ambulatory systolic BP measurement ≥135 mmHg. All patients underwent catheter-based renal denervation (RDN) using a newly designed RDN System (Golden Leaf Medtech, Shanghai, China). For up to 6 months after RDN, BP was monitored and renal function was assessed. Mean baseline office BP was 165.0 ± 13.9/97.8 ± 5.5 mmHg, despite treatment with three antihypertensive drugs. Six months after RDN, office BP was reduced by 22.1 ± 12.0 (P = .002)/11.0 ± 8.8 mmHg (P = .012) and average 24 h ambulatory BP by 18 ± 13.7 (P = .01)/9.3 ± 7.7 mmHg (P = .016). After RDN, heart rate and estimated glomerular filtration rate (GFR) had no significant change compared with before RDN. In Chinese patients with CKD, our observational pilot study found that treating hypertension with RDN lowers BP while not affecting renal function. Brief Abstract: We performed RDN in eight Chinese patients with hypertension and CKD. The results showed that RDN lowered blood pressure of these patients significantly and eGFR was stable. No obvious adverse event was observed.

A Retrospective Study of the Perioperative Period Management of Joint Arthroplasty in Patients with Chronic Kidney Disease

OBJECTIVE

With the rising prevalence of chronic kidney disease (CKD) and the increasing demand for joint arthroplasty, the management of CKD patients in the perioperative period of joint arthroplasty has become an issue worthy of attention for orthopedic surgeons. This study aimed to explore comprehensive perioperative period management strategies for CKD patients.

METHODS

From March 2017 to August 2022, 62 patients who underwent joint arthroplasty in our hospital were included in a retrospective study, including 31 CKD patients (mean age 69.8 ± 13.4 years old) and 31 non-CKD patients (mean age 69.4 ± 14.2 years old). The outcome indicators were analyzed, including serum urea, serum creatinine, blood uric acid, hematocrit, and hemoglobin.

RESULTS

All patients included in the retrospective study had an average preoperative preparation time of 4.3 ± 2.6 days and an average hospitalization time of 11.0 ± 7.3 days. There were no significant differences in the changes in the serum urea values between the preoperative and postoperative measurements in the CKD patients or in the serum creatinine values and blood uric acid values (P > 0.05). The hemoglobin value in postoperative measurements was lower than in preoperative measurements in the CKD patients (P < 0.05). The hematocrit value in postoperative measurements was lower than in preoperative measurements in the CKD patients (P < 0.001).

CONCLUSION

Patients with CKD have distinct characteristics compared to non-CKD patients, and they generally have a higher risk for postoperative complications and adverse events. Recognition of risk factors, suitable timing of surgery, the undertaking of protective strategies, and proper management of complications are vital for managing CKD patients in the perioperative period of joint arthroplasty.

Timed-averaged blood pressure showed a J-curve association with stroke in elderly chronic kidney disease patients

BACKGROUND

The risk factors for stroke in elderly patients with chronic kidney disease (CKD) are not well understood. This study aimed to explore the influence of systolic blood pressure (SBP) on the risk of stroke in a large cohort of elderly patients with stage 3-5 CKD.

METHODS

We retrospectively identified 665 patients hospitalized in Beijing Friendship Hospital from January 2000 to December 2021. Patients were followed up until the occurrence of stroke or death. Multivariate logistic regression analysis and Cox proportional hazard models were used to analyze the risk factors for stroke according to the presence or absence of CKD. The association between CKD and stroke was further evaluated regarding the role of SBP in the hypertensive population.

RESULTS

In individuals with CKD, a J-shaped relationship was observed between SBP levels and the risk of stroke. Participants with CKD and an SBP less than 125 mmHg had a significantly higher cumulative stroke survival rate than those whose SBP was between 125 and 139 mmHg. The cumulative stroke survival rate increased progressively for those with SBP higher than 140 mmHg. This J-shaped relationship was not found in patients without CKD.

CONCLUSION

In elderly patients with CKD, those with the lowest BP are at increased risk for incident stroke. This phenomenon could be different from that in the general population.

A comparative post hoc analysis of finerenone and spironolactone in resistant hypertension in moderate-to-advanced chronic kidney disease

Background

Mineralocorticoid receptor antagonists (MRAs) reduce systolic blood pressure (SBP) and increase serum potassium concentration ([K⁺]). This indirect comparison investigated any differences in SBP-lowering and hyperkalemia risk between finerenone, a nonsteroidal MRA, and the steroidal MRA spironolactone ± a potassium binder.

Methods

In FIDELITY (a pooled analysis of FIDELIO-DKD and FIGARO-DKD), a subgroup of patients with treatment-resistant hypertension (TRH) and chronic kidney disease meeting eligibility criteria of the AMBER trial were identified (FIDELITY-TRH). The main outcomes were mean change in SBP, incidence of serum [K⁺] ≥5.5 mmol/L and hyperkalemia-associated treatment discontinuation. Results at ∼17 weeks were compared with 12 weeks from AMBER.

Results

In 624 FIDELITY-TRH patients and 295 AMBER patients, the least squares mean change in SBP (mmHg) from baseline was -7.1 for finerenone and -1.3 for placebo {between-group difference -5.74 [95% confidence interval (CI) -7.99 to -3.49], P < .0001} versus -11.7 for spironolactone + patiromer and -10.8 for spironolactone + placebo [between-group difference -1.0 (95% CI -4.4-2.4), P = .58]. The incidence of serum [K⁺] ≥5.5 mmol/L was 12% for finerenone and 3% for placebo versus 35% with spironolactone + patiromer and 64% with spironolactone + placebo. Treatment discontinuation due to hyperkalemia was 0.3% for finerenone and 0% for placebo versus 7% for spironolactone + patiromer and 23% for spironolactone + placebo.

Conclusions

In patients with TRH and chronic kidney disease compared with spironolactone with or without patiromer, finerenone was associated with a lower SBP reduction and lower risk of hyperkalemia and treatment discontinuation.Trial Registration: AMBER (NCT03071263), FIDELIO-DKD (NCT02540993), FIGARO-DKD (NCT02545049).

Prevalence of Apparent Treatment-Resistant Hypertension in Chronic Kidney Disease in Two Large US Health Care Systems

BACKGROUND AND OBJECTIVES

More intensive BP goals have been recommended for patients with CKD. We estimated the prevalence of apparent treatment-resistant hypertension among patients with CKD according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA; BP goal <130/80 mm Hg) and 2021 Kidney Disease Improving Global Outcomes (KDIGO; systolic BP <120 mm Hg) guidelines in two US health care systems.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We included adults with CKD (an eGFR <60 ml/min per 1.73 m2) and treated hypertension from Kaiser Permanente Southern California and the Veterans Health Administration. Using electronic health records, we identified apparent treatment-resistant hypertension on the basis of (1) BP above the goal while prescribed three or more classes of antihypertensive medications or (2) prescribed four or more classes of antihypertensive medications regardless of BP. In a sensitivity analysis, we required diuretic use to be classified as apparent treatment-resistant hypertension. We estimated the prevalence of apparent treatment-resistant hypertension per clinical guideline and by CKD stage.

RESULTS

Among 44,543 Kaiser Permanente Southern California and 241,465 Veterans Health Administration patients with CKD and treated hypertension, the prevalence rates of apparent treatment-resistant hypertension were 39% (Kaiser Permanente Southern California) and 35% (Veterans Health Administration) per the 2017 ACC/AHA guideline and 48% (Kaiser Permanente Southern California) and 55% (Veterans Health Administration) per the 2021 KDIGO guideline. By requiring a diuretic as a criterion for apparent treatment-resistant hypertension, the prevalence rates of apparent treatment-resistant hypertension were lowered to 31% (Kaiser Permanente Southern California) and 23% (Veterans Health Administration) per the 2017 ACC/AHA guideline. The prevalence rates of apparent treatment-resistant hypertension were progressively higher at more advanced stages of CKD (34%/33%, 42%/36%, 52%/41%, and 60%/37% for Kaiser Permanente Southern California/Veterans Health Administration eGFR 45-59, 30-44, 15-29, and <15 ml/min per 1.73 m2, respectively) per the 2017 ACC/AHA guideline.

CONCLUSIONS

Depending on the CKD stage, up to a half of patients with CKD met apparent treatment-resistant hypertension criteria.

Renal denervation in the antihypertensive arsenal - knowns and known unknowns

Even though it has been more than a decade since renal denervation (RDN) was first used to treat hypertension and an intense effort on researching this therapy has been made, it is still not clear how RDN fits into the antihypertensive arsenal. There is no question that RDN lowers blood pressure (BP), it does so to an extent at best corresponding to one antihypertensive drug. The procedure has an excellent safety record. However, it remains clinically impossible to predict whose BP responds to RDN and whose does not. Long-term efficacy data on BP reduction are still unconvincing despite the recent results in the SPYRAL HTN-ON MED trial; experimental studies indicate that reinnervation is occurring after RDN. Although BP is an acceptable surrogate endpoint, there is complete lack of outcome data with RDN. Clear indications for RDN are lacking although patients with resistant hypertension, those with documented increase in activity of the sympathetic system and perhaps those who desire to take fewest medication may be considered.

Etiology and Management of Treatment-Resistant Hypertension in African American Adults ≥18 Years: A Literature Review

Treatment-resistant hypertension (TRH) is defined as blood pressure levels that remain above the therapeutic goal despite concurrent use of three or more antihypertensive medications taken at maximally tolerated doses, one of which should be a diuretic. Additionally, individuals on four or more antihypertensive agents regardless of blood pressure are also considered to have TRH. Amongst people diagnosed with TRH, African American adults face a huge management gap, resulting in increased cardiovascular disease risk. The primary objective of this review was to identify the commonly encountered etiologies and extensively discuss the current management strategies of TRH with a particular focus on African Americans. Relevant studies were identified by analyzing scientific databases and journals such as PubMed, Cochrane, MEDLINE, Cureus, and American Heart Association (AHA). The studies identified and examined common causes of TRH, describing their pathophysiology and highlighting different treatment options for the respective etiologies. The most prevalent etiologies of TRH amongst African Americans were chronic kidney disease (CKD), renal artery stenosis (RAS), fibromuscular dysplasia, obstructive sleep apnea (OSA), endocrine causes (Conn syndrome, Cushing syndrome, etc.), sympathetic nervous system overactivity, lifestyle factors, inaccurate blood pressure measurement, and inappropriate treatment. Of the etiologies reviewed, OSA, lifestyle factors, and CKD exhibited a striking prevalence among the subpopulation studied. Unfortunately, there was a paucity of articles addressing this topic amongst African Americans, and therefore there was not a substantial appreciation of the prevalence of some of the identified etiologies in the population of interest. Thorough diagnostic testing for associated or underlying conditions provides a basis for successful management. This review brought to the fore the need for doctors and patients to collaborate in order to improve TRH management and help patients lead healthier lives.

Epidemiology and outcomes of hypertensive crisis in patients with chronic kidney disease: a nationwide analysis

BACKGROUND

The epidemiology and outcomes of hypertensive crisis (HTN-C) in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) have not been well studied. The objective of our study is to describe the incidence, clinical characteristics, and outcomes of emergency department (ED) visits for HTN-C in patients with CKD and ESRD.

METHODS

We performed a secondary analysis of Nationwide Emergency Department Sample databases for years 2016-2018 by identifying adult patients presenting to ED with hypertension related conditions as primary diagnosis using appropriate diagnosis codes.

RESULTS

There were 348 million adult ED visits during the study period. Of these, 680 333 (0.2%) ED visits were for HTN-C. Out of these, majority were in patients without renal dysfunction (82%), with 11.4 and 6.6% were in patients with CKD and ESRD, respectively. The CKD and ESRD groups had significantly higher percentages of hypertensive emergency (HTN-E) presentation than in the No-CKD group (38.9, 34.2 and 22.4%, respectively; P  < 0.001). ED visits for HTN-C frequently resulted in hospital admission and these were significantly higher in patients with CKD and ESRD than in No-CKD (78.3 vs. 72.6 vs. 44.7%; P  < 0.0001). In-hospital mortality was overall low but was higher in CKD and ESRD than in No-CKD group (0.3 vs. 0.2 vs. 0.1%; P  < 0.0001), as was cost of care (USD 28 534, USD 29 465 and USD 26 394, respectively; P  < 0.001).

CONCLUSION

HTN-C constitutes a significant burden on patients with CKD and ESRD compared with those without CKD with a higher proportion of ED visits, incidence of HTN-E, hospitalization rate, in-hospital mortality and cost of care.

GRAPHICAL ABSTRACT

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Development and Validation of a Prognostic Nomogram for Prognosis in Patients With Renal Artery Stenosis

Background and Objective

Renal artery stenosis (RAS) is associated with an increased risk of renal function deterioration (RFD). Our previous study showed that renal cortical blood perfusion assessed by contrast-enhanced ultrasound (CEUS) was an important related factor for RFD in RAS patients. Based on several conventional related factors confirmed by previous studies, we aimed to establish and verify a CEUS+ scoring system to evaluate the risk of RFD at 1 year of follow-up in RAS patients.

Methods

This study was a single-center retrospective study. A total of 497 elderly RAS patients (247 in the training group and 250 in the verification group) admitted to the Beijing Hospital from January 2016 to December 2019 were included. The baseline characteristics of the patients on admission (including general conditions, previous medical history, blood pressure, blood creatinine, RAS, and cortical blood perfusion in the affected kidney) and renal function [glomerular filtration rate (GFR)] at 1-year of follow-up were collected. We used the univariate and multivariate logistic regressions to establish a CEUS+ scoring system model, the receiver operating characteristic (ROC) curve and area under the curve (AUC) to evaluate prediction accuracy, and the decision curve analysis and nomogram to evaluate the clinical application value of CEUS+ scoring system model.

Results

Among the 497 patients enrolled, 266 (53.5%) were men, with an average age of (51.7 ± 19.3) years. The baseline clinical-radiomic data of the training group and the verification group were similar (all p > 0.05). Multivariate logistic regression analysis results showed that age [Odds ratio (OR) = 1.937, 95% confidence interval (CI): 1.104–3.397), diabetes (OR = 1.402, 95% CI: 1.015–1.938), blood pressure (OR = 1.575, 95% CI: 1.138–2.182), RAS (OR = 1.771, 95% CI: 1.114–2.816), and area under ascending curve (AUCi) (OR = 2.131, 95% CI: 1.263–3.596) were related factors for the renal function deterioration after 1 year of follow-up (all p < 0.05). The AUC of the ROC curve of the CEUS+ scoring system model of the training group was 0.801, and the Youden index was 0.725 (specificity 0.768, sensitivity 0.813); the AUC of the ROC curve of the validation group was 0.853, Youden index was 0.718 (specificity 0.693, sensitivity 0.835). There was no significant difference in ROC curves between the two groups (D = 1.338, p = 0.325). In addition, the calibration charts of the training and verification groups showed that the calibration curve of the CEUS+ scoring system was close to the standard curve (p = 0.701, p = 0.823, both p > 0.10).

Conclusion

The CEUS+ scoring system model is helpful in predicting the risk of worsening renal function in elderly RAS patients.

The Burden of Resistant Hypertension Across the World

PURPOSE OF REVIEW

Resistant hypertension (R-HTN) is related to worse cardiovascular, renal outcomes, and death compared to non R-HTN. We aimed to review the burden of R-HTN across the world, focusing on its prevalence, associated factors and outcomes, and the impact of treatment.

RECENT FINDINGS

R-HTN prevalence among hypertensive individuals varies around 10-20%, depending on the population and definition applied. R-HTN consistently relates to older age, chronic kidney disease, obesity, and obstructive sleep apnea - which are increasing in prevalence with global population aging. As such, R-HTN prevalence is also expected to rise. Infrequent use of ambulatory blood pressure monitoring to identify at higher risk individuals and poor adherence to treatment are still barriers in the approach of R-HTN. Available evidence suggests that 10-20% of patients with hypertension have R-HTN. However, the prevalence of true R-HTN using contemporaneous standardized definitions is still unknown. Novel strategies to address clinicians, patients and health system barriers to treatment inertia and adherence are fundamental to reduce the burden of R-HTN.

Alamandine alleviates hypertension and renal damage via oxidative-stress attenuation in Dahl rats

Alamandine (Ala) is a novel member of the renin-angiotensin-system (RAS) family. The present study aimed to explore the effects of Ala on hypertension and renal damage of Dahl salt-sensitive (SS) rats high-salt diet-induced, and the mechanisms of Ala on renal-damage alleviation. Dahl rats were fed with high-salt diets to induce hypertension and renal damage in vivo, and HK-2 cells were treated with sodium chloride (NaCl) to induce renal injury in vitro. Ala administration alleviated the high-salt diet-induced hypertension, renal dysfunction, and renal fibrosis and apoptosis in Dahl SS rats. The HK-2 cells' damage, and the increases in the levels of cleaved (c)-caspase3, c-caspase8, and c-poly(ADP-ribose) polymerase (PARP) induced by NaCl were inhibited by Ala. Ala attenuated the NaCl-induced oxidative stress in the kidney and HK-2 cells. DETC, an inhibitor of SOD, reversed the inhibitory effect of Ala on the apoptosis of HK-2 cells induced by NaCl. The NaCl-induced increase in the PKC level was suppressed by Ala in HK-2 cells. Notably, PKC overexpression reversed the moderating effects of Ala on the NaCl-induced apoptosis of HK-2 cells. These results show that Ala alleviates high-salt diet-induced hypertension and renal dysfunction. Ala attenuates the renal damage via inhibiting the PKC/reactive oxygen species (ROS) signaling pathway, thereby suppressing the apoptosis in renal tubular cells.

Clinical and Renal Cortical Blood Perfusion Characteristics in Patients with Severe Atherosclerotic Renal Artery Stenosis Who Underwent Stent Implantation: A Single-center Retrospective Cohort Study

Objective This study aimed to observe the clinical imaging features of patients with severe atherosclerotic renal artery stenosis (ARAS) receiving stent implantation, and to evaluate the associations between baseline clinical and imaging factors and renal-function deterioration at a 1-year follow-up.Methods This study was a single-center retrospective cohort study. A total of 159 patients with unilateral severe ARAS who underwent stent implantation at Beijing Hospital between July 2017 and December 2020 were consecutively enrolled. According to the renal glomerular filtration rate (GFR), detected by radionuclide renal imaging at 1-year follow-up, all patients were divided into a poor-prognosis group (with a ≥30% decrease in renal GFR; n=32 cases) and a control group (127 cases). Clinical imaging data, including the renal cortical blood perfusion pre- and post-sent implantation, were analyzed. Univariate and multivariate logistic regression analysis was used to evaluate the associations between clinical and imaging factors and renal-function deterioration.Results Of the 159 patients enrolled, 83 (52.2%) were men, with an average age of (57.2±14.7) years. The patient age, rate of diabetes, and systolic blood and diastolic blood pressure in the poor-prognosis group were significantly higher than those in the control group (all P<0.05). Before stent treatment, patients in the poor-prognosis group, compared with the control group, had a significantly smaller area under the ascending curve (AUC1), area under the descending curve (AUC2), and peak intensity (PI), and a longer time to peak intensity (TTP) and mean transit time (MTT) (all P<0.05). After stent treatment, patients in the poor-prognosis group, compared with the control group, showed significantly smaller AUC1, AUC2, and PI, and longer MTT (all P<0.05). Multivariate logistic regression analysis indicated that age (OR=1.251, 95%CI: 1.113–1.406, P=0.0002), diabetes (OR=1.472, 95%CI: 1.110–1.952, P=0.007), systolic blood pressure (OR=1.339, 95%CI: 1.082–1.657, P=0.007), renal GFR (OR=2.025, 95%CI: 1.217–3.369, P=0.006), and AUC1 post-stent (OR=2.173, 95%CI: 1.148–4.113, P=0.017) were the factors associated with renal deterioration at the 1-year follow-up.Conclusions Patients with severe RAS with renal-function deterioration after stent implantation were older, and often had diabetes, hypertension, and impaired renal cortical perfusion. Age, diabetes, systolic blood pressure, renal GFR, and AUC1 after stent implantation were independent factors associated with short-term renal deterioration.

Interactions Between Kidney Function and Cerebrovascular Disease: Vessel Pathology That Fires Together Wires Together

The kidney and the brain, as high-flow end organs relying on autoregulatory mechanisms, have unique anatomic and physiological hemodynamic properties. Similarly, the two organs share a common pattern of microvascular dysfunction as a result of aging and exposure to vascular risk factors (e.g., hypertension, diabetes and smoking) and therefore progress in parallel into a systemic condition known as small vessel disease (SVD). Many epidemiological studies have shown that even mild renal dysfunction is robustly associated with acute and chronic forms of cerebrovascular disease. Beyond ischemic SVD, kidney impairment increases the risk of acute cerebrovascular events related to different underlying pathologies, notably large artery stroke and intracerebral hemorrhage. Other chronic cerebral manifestations of SVD are variably associated with kidney disease. Observational data have suggested the hypothesis that kidney function influences cerebrovascular disease independently and adjunctively to the effect of known vascular risk factors, which affect both renal and cerebral microvasculature. In addition to confirming this independent association, recent large-scale human genetic studies have contributed to disentangling potentially causal associations from shared genetic predisposition and resolving the uncertainty around the direction of causality between kidney and cerebrovascular disease. Accelerated atherosclerosis, impaired cerebral autoregulation, remodeling of the cerebral vasculature, chronic inflammation and endothelial dysfunction can be proposed to explain the additive mechanisms through which renal dysfunction leads to cerebral SVD and other cerebrovascular events. Genetic epidemiology also can help identify new pathological pathways which wire kidney dysfunction and cerebral vascular pathology together. The need for identifying additional pathological mechanisms underlying kidney and cerebrovascular disease is attested to by the limited effect of current therapeutic options in preventing cerebrovascular disease in patients with kidney impairment.

Tagetes erecta L. flowers, a medicinal plant traditionally used to promote diuresis, induced diuretic and natriuretic effects in normotensive and hypertensive rats

ETHNOPHARMACOLOGICAL RELEVANCE

Tagetes erecta L., known as marigold, belongs to the Asteraceae family and is mainly found in South America. Despite reports that T. erecta flowers are used in folk medicine to treat cardiovascular and renal diseases, there is no study regarding its diuretic effect.

AIM

This study aimed to evaluate the chemical composition and the diuretic efficacy of the hydroethanolic extract from T. erecta (HETE) in normotensive (NTR) and hypertensive (SHR) rats.

MATERIAL AND METHODS

The HETE was analyzed by liquid chromatography coupled to diode array detector and mass spectrometry (LC-DAD-MS). Female and male NTR and SHR received the treatment with vehicle, HETE (0.01 mg/kg, 0.1 mg/kg, and 1 mg/kg) or hydrochlorothiazide (HCTZ; 5 mg/kg) orally. The urinary parameters were measured at the end of the 8-h experiment.

RESULTS

From HETE, saccharides and triterpenes were the main annotated compounds, such as erythrodiol and β-amyrin. The urine volume was significantly increased in the groups treated with HETE, in both male and female NTR and SHR rats, compared to the respective vehicle-treated groups. Regarding electrolytes elimination, the treatment with HETE did not reveal significant changes in the urine levels of K⁺ or Cl^-, but it showed a natriuretic and Ca²⁺-sparing effects. The HETE beneficial result in reducing Ca²⁺ excretion was confirmed through the protective effect found in front of the urinary calcium oxalate precipitation and crystallization. The combination with HCTZ, a classic diuretic and saluretic medicine, significantly enhanced HETE-induced diuresis, natriuresis, and the Ca²⁺-sparing effect. On the other hand, the K⁺-sparing action was improved in the combination of HETE with amiloride, a standard K⁺-sparing diuretic. In contrast, the combination of HETE with atropine (a non-selective muscarinic receptor antagonist) and indomethacin (an inhibitor of the cyclooxygenase enzyme), promoted an important reduction in urinary volume, but interestingly the natriuretic effect was maintained.

CONCLUSION

This study contributed to the preclinical validation of the diuretic efficacy of T. erecta, highlighting this species as promising for the development of new pharmacological strategies for the management of kidney disorders.

The safety and efficacy of low-dose mineralocorticoid receptor antagonists in dialysis patients: A meta-analysis

INTRODUCTION

Our aim was to evaluate the safety and efficacy of low-dose mineralocorticoid receptor antagonists (MRAs) in dialysis patients.

METHODS

We systematically searched PubMed, EMBASE, and Cochrane libraries for clinical trials on the use of MRAs in dialysis patients. Review Manager 5.3 software was used to analyze relevant data and evaluate the quality of evidence.

RESULTS

We identified nine randomized controlled trials including 1128 chronic dialysis patients. In terms of safety, when hyperkalemia was defined as serum potassium level ≥5.5 mmol/L, low-dose MRAs were significantly associated with hyperkalemia (relative risk [RR] 1.76, 95% confidence intervals [CI] 1.07-2.89, P = .02); however, when hyperkalemia was defined as serum potassium level ≥6.0 mmol/L or serum potassium level ≥6.5 mmol/L, no significant association was observed between low-dose MRAs and hyperkalemia (RR 1.40, 95% CI 0.83-2.37, P = .20; RR 1.98, 95% CI 0.91-4.30, P = .09, respectively). Use of low-dose MRAs can reduce cardiovascular mortality by 54% compared with the control group (0.46, 95% CI 0.28-0.76, P = .003). Similarly, the RR of all-cause mortality for the low-dose MRAs group was 0.48 (95% CI 0.33-0.72, P = .0003).

CONCLUSION

Low-dose MRAs may benefit dialysis patients without significantly increasing moderate to severe hyperkalemia.

Afferent renal innervation in anti-Thy1.1 nephritis in rats

Afferent renal nerves exhibit a dual function controlling central sympathetic outflow via afferent electrical activity and influencing intrarenal immunological processes by releasing peptides such as calcitonin gene-related peptide (CGRP). We tested the hypothesis that increased afferent and efferent renal nerve activity occur with augmented release of CGRP in anti-Thy1.1 nephritis, in which enhanced CGRP release exacerbates inflammation. Nephritis was induced in Sprague-Dawley rats by intravenous injection of OX-7 antibody (1.75 mg/kg), and animals were investigated neurophysiologically, electrophysiologically, and pathomorphologically 6 days later. Nephritic rats exhibited proteinuria (169.3 ± 10.2 mg/24 h) with increased efferent renal nerve activity (14.7 ± 0.9 bursts/s vs. control 11.5 ± 0.9 bursts/s, n = 11, P < 0.05). However, afferent renal nerve activity (in spikes/s) decreased in nephritis (8.0 ± 1.8 Hz vs. control 27.4 ± 4.1 Hz, n = 11, P < 0.05). In patch-clamp recordings, neurons with renal afferents from nephritic rats showed a lower frequency of high activity following electrical stimulation (43.4% vs. 66.4% in controls, P < 0.05). In vitro assays showed that renal tissue from nephritic rats exhibited increased CGRP release via spontaneous (14 ± 3 pg/mL vs. 6.8 ± 2.8 pg/ml in controls, n = 7, P < 0.05) and stimulated mechanisms. In nephritic animals, marked infiltration of macrophages in the interstitium (26 ± 4 cells/mm²) and glomeruli (3.7 ± 0.6 cells/glomerular cross-section) occurred. Pretreatment with the CGRP receptor antagonist CGRP_8-37 reduced proteinuria, infiltration, and proliferation. In nephritic rats, it can be speculated that afferent renal nerves lose their ability to properly control efferent sympathetic nerve activity while influencing renal inflammation through increased CGRP release.