Recomendations for Managing Hypertension in the Elderly with CKD
Though a lack of data exists regarding the treatment of hypertension in elderly patients with the comorbidity of CKD, given the consistent and robust data that exists demonstrating a reduction in cardiovascular risk and mortality in the general elderly population without renal impairment, it is our opinion that elderly patients with CKD and hypertension should receive antihypertensive treatment. This opinion is supported by the fact that in the recently published SPRINT trial, 28.1% of patients in the standard treatment arm (targeting a blood pressure of less than 140 mm Hg), and 28.4% of patients in the intensive treatment arm (blood pressure target less than 120 mm Hg) had CKD, and similarly 28.2% of the trial participants in each group were greater than the age of 75. The percentage of patients with both CKD and age greater than 75 years was not reported in the initial trial results, though it is assumed a significant portion of these patients had both CKD and age greater than 75 years. It is nonetheless reassuring that patients with CKD in the SPRINT trial, as well as those with age > 75 years, both seemed to derive the same benefit in cardiovascular and mortality benefit in the intensive treatment arm compared to the standard treatment arm [53].
It should be noted, however, that though cardiovascular events and mortality were lower in the more intensive treatment arm of the SPRINT trial, CKD progression did not differ between the two treatment groups. Additionally, the risk of acute kidney injury was significantly greater in the intensive treatment arm when compared to the standard treatment arm, with 3.8% of patients in the intensive treatment arm suffering AKI compared to 2.3% in the standard arm [22]. Thus, it should be understood by both the clinician and the elderly patient with hypertension and CKD that the goal of more aggressively lowering blood pressure is to prevent cardiovascular events and not slow renal disease progression.
The recently published 2017 hypertension guidelines by the American College of Cardiology/American Heart Association is the most comprehensive set of hypertension treatment recommendations published to date and includes a section regarding patients with CKD as well as a section on the elderly [54]. Regarding CKD, the guidelines recommend a goal blood pressure of less than 130/80 mm Hg in patients with CKD, and that patients with macroalbuminuria (defined as a daily urine protein excretion of greater than 300 mg/dL or a urine albumin to creatinine ratio of 300 mg/g) be treated with and angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB). We feel these are reasonable recommendations for CKD targets and agree with the guideline, with the understanding that the target of 130/80 mm Hg is based largely on the SPRINT data. It is important to recognize that in the Action to Control Cardiovascular Risk in Diabetes trial (ACCORD), a more intensive blood pressure target of 120 mm Hg did not result in further improvement in cardiovascular events compared to a traditional target of 140/90 mm Hg [55]. However, given the larger and more robust sample size from SPRINT, we feel the target of 130/80 mm Hg is warranted and therefore should be the first target for elderly patients with CKD. With this goal in mind, it has been our clinical experience that some elderly patients with CKD have difficulty tolerating this goal, either from the development of worsening of GFR, acute kidney injury events, or due to orthostatic hypotension. Additionally, it should be noted that patients with orthostatic hypotension were excluded from SPRINT, though an increase in falls was not seen in the primary study. Therefore, for patients who are unable to tolerate the SPRINT goal of 130/80 mm Hg, an individualized goal of at least less than 160 mm Hg systolic and ideally less than 140 mm Hg, reflecting achieved blood pressure endpoints from earlier trials, may be a reasonable alternative [55]. The recent hypertension guidelines also recommend that for elderly adults with a high burden of comorbidities or limited life expectancy, “clinical judgement, patient preference, and at team-based approach to risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs.” We agree that all treatment decisions must be individualized based upon each patient’s clinical scenario, and that a guideline is only a general aid for treatment decisions, not a mandate for care.
Therefore, with the acknowledgement that there is a lack of literature specifically examining blood pressure goals in elderly patients with CKD, it is our opinion based on available evidence that the following suggestions constitute a reasonable approach to this scenario: (1) a blood pressure target of less than 130/80 mm Hg should be sought as the primary blood pressure target; (2) if the patient cannot tolerate this due to rapidly declining GFR, acute kidney injury, orthostatic hypotension and or falls; or in other situations where this is not a practical a goal, individualized goal of at ideally less than 140 mm Hg, though at least less than 160 mm Hg systolic, could be considered; (3) the clinician should attempt careful and gradual reduction of blood pressure, with no more than one agent added or one escalation of medication dose attempted per visit; (4) the patient should have close follow up-after medication changes with an adjustment period of at least 4 weeks before additional medication or dose escalations are made; (5) if CKD is accompanied by albuminuria (daily urine protein excretion of greater than 300 mg/dL or a urine albumin to creatinine ratio of 300 mg/g) an ACEI or ARB should be used in management; (6) a rise in serum creatinine of up to 30% of baseline after addition of an ACEI may be acceptable; however, a rise greater than this amount should prompt discontinuation of the drug and evaluation for renal artery stenosis; (7) frequent monitoring of creatinine is required, with repeat chemistry performed after medication adjustments; (8) patients with a high pulse pressure should be monitored especially closely for symptoms or changes in renal function; and finally (9) individualized treatment and clinical judgement, with the patient being an informed participant, should take priority over all other recommendations and guidelines. We feel that further research in this growing subgroup of elderly patients is needed and will be sought, and we expect recommendations will continue to evolve as future literature becomes available.
Corresponding author: Jonathan G. Owen, MD, MSC04 2785, 1 University of New Mexico, Albuquerque, NM 87131, jowen@salud.unm.edu.
Financial disclosures: None.
Author contributions: conception and design, JGO; analysis and interpretation of data, KA, FXR, JGO; drafting of article, KA, FXR, JGO; critical revision of the article, KA, FXR, JGO; collection and assembly of data, KA, FXR, JGO.