HYPERTENSION AND THE KIDNEY

Linda Armelia

Blood Pressure Assessment:Patient preparation and posture

Standardized Preparation:

Patient1. No acute anxiety, stress or pain2. No caffeine, smoking or nicotine in the preceding 30 minutes3. No use of substances containing adrenergic stimulants such as

phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops).

4. Bladder and bowel comfortable5. No tight clothing on arm or forearm6. Quiet room with comfortable temperature 7. Rest for at least 5 minutes before measurement8. Patient should stay silent prior and during the procedure.

Blood Pressure Assessment:Patient preparation and posture

Standardized technique:

Posture• The patient should be

calmly seated with his or her back well supported and arm supported at the level of the heart.

• His or her feet should touch the floor and legs should not be crossed.

Pendahuluan • Riskesdas 2007:

– hipertensi di Indonesia mencapai 31,7 persen dari populasi pada usia 18 tahun ke atas.

– 60% penderita hipertensi berakhir penyakit stroke, dan sisanya mengalami gangguan jantung, gagal ginjal dan kebutaan.

– hipertensi sebagai penyebab kematian nomor tiga setelah stroke dan tuberkulosis

– Jumlahnya mencapai 6,8 % dari proporsi penyebab kematian pada semua umur di Indonesia.

Pengaturan Tekanan Darah

Faktor-faktor yang mengontrol Tekanan Darah

Definisi

Circulation. 2000;102:IV-40 –IV-45

European Society of Hypertension Classification of Blood Pressure

Category Systolic Diastolic

Optimal <120 and / or <80

Normal <130 and / or <85

High-Normal 130-139 and / or 85-89

Grade 1 (mild hypertension ) 140-159 and / or 90-99

Grade 2 (moderate hypertension) 160-179 and / or 100-109

Grade 3 (severe hypertension) 180 and / or 110

Isolated Systolic Hypertension (ISH) 140 and <90

The category pertains to the highest risk blood pressure*ISH=Isolated Systolic Hypertension.

J Hypertens 2007;25:1105-87

JNC VII (American) Classification of Blood Pressure

Category Systolic Diastolic

Optimal <120 and / or <80

Normal <130 and / or <85

High-Normal 130-139 and / or 85-89

Stage 1 (mild hypertension ) 140-159 and / or 90-99

Stage 2 (moderate to severe hypertension)

160 and / or 100-109

Isolated Systolic Hypertension (ISH) 140 and <90

The category pertains to the highest risk blood pressure*ISH=Isolated Systolic Hypertension.

JAMA 2003;289:2560-72

Penyebab Hipertensi

Hipertensi Resisten

• Refraktori• TD tidak tercapai setelah pemberian regimen

3 obat yang adekuat termasuk diuretik, 3 regimen tersebut mendekati maksimal dosis

• Perburukan TD pada GGK tanda progresi; risiko tinggi volume-dependent hypertension

• Berkembang krisis hipertensi [>180/120 mm Hg] dengan atau tanpa penundaan atau progresif disfunsgi organ

Evaluasi Hipertensi• Menilai gaya hidup dan

indentifikasi faktor-faktor kardiovaskular prognosis dan tatalaksana

• Indentifikasi etiologi• Menilai ada atau

tidaknya kerusakan organ dan penyakit kardiovakular

Pemeriksaan Laboratorium

• Awal terapi• EKG• Urinalisis, gula darah, hemotokrit, kalium,

kreatinin [eGFR], kalsium, profil lipid• Lain: ekskresi albumin urin atau rasio

albumin/kreatinin

Identifikasi Penyebab Hipertensi

• Tes diagnostik terutama– usia, riwaayat perjalanan penyakit, pemeriksaan

fisik, tingkat keparahan hipertensi, laboratorium abnormal

– TD kurang respons dengan terapi yg diberikan– TD mulai meningkat tanpa diketahui penyebabnya

setelah terkontrol dg baik– Awitan hipertensi timbul mendadak

Identifikasi Penyebab HipertensiRenal artery stenosis and subsequent renovascularhypertension dicuriga:(1)awitan hipertensi usia <30 tahun, tidak ada riwayat

keluarga hipertensi, awitan hipertensi usia > 55 tahun(2)bruit abdominal terutama terdapat komponen

diastolik(3) accelerated hypertension(4) hipertensi awalnya mudah dikontrol resisten (5) edema pulmonal berulang(6) gagal ginjal dg etiologi belum jelas, terutama tidak

ada proteinuria

Rekomendasi Follow Up Tekanan Darah

Target Terapi

• Mencapai pengurangan maksimal risiko jangka panjang penyakit kardiovaskular

• TD <140/90 mmHg (systolik/diastolik)• Target TD <130/80 mmHg diabetes, risiko tinggi:

stroke, infark myocardial, disfungsi ginjal, proteinuria• Agar lebih mudah mencapai tekanan darah yang

diinginkan terapi antihipertensi harus dilakukan sebelum adanya kerusakan kardiovaskular yg signifikan

http://www.kidney.org/professionals/kdoqi/guidelines_bp/images/table91l.jpg

Evaluasi Terapi Hipertensi pada PGK

Complications of Hypertension:Complications of Hypertension:End-Organ DamageEnd-Organ Damage

Chobanian AV, et al. JAMA. 2003;289:2560-2572.

Peripheral Vascular Disease Renal Failure,

Proteinuria

LVH, CHD, CHFHemorrhage,Stroke

RetinopathyCHD = coronary heart diseaseCHF = congestive heart failureLVH = left ventricular hypertrophy

Hypertension

Slide SourceHypertension Online

www.hypertensiononline.org

Modifiable risks for developing hypertension

• Obesity• Poor dietary habits• High sodium intake• Sedentary lifestyle• High alcohol consumption

Modifikasi gaya hidup untuk pengendalian Hipertensi

Modifikasi Rekomendasi Penurunan Tekanan Darah Sistolik kurang

lebihMenurunkan berat badan Pelihara berat badan

normal (BMI 18.5-24.9)5-20 mm Hg utk setiap penurunan 10 kg BB

Menjalankan menu DASH Konsumsi makanan kaya buah, sayur, susu rendah lemak dan rendah lemak jenuh

8-14 mm Hg

Mengurangi asupan garam/sodium

Kurangi natrium sampai tidak lebih dari 2.4 g/hari atau NaCl 6 g/hari

2-8 mm Hg

Meningkatkan aktifitas fisik

Berolahraga erobik teratur seperti misalnya berjalan kaki (30 men/hari 4-5 hari seminggu)

4-9 mm Hg

Kurangi konsumsi alkohol Batasi konsumsi alkohol,jangan lebih dari 2 /hari utk pria dan 1 /hari utk perempuan.

2-4 mm HgSource: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

Main classes of antihypertensive drugs

Diuretics Inhibit the reabsorption of salts and water from kidney tubules into the bloodstream

Calcium-channel antagonists Inhibit influx of calcium into cardiac and smooth muscle

Beta-blockers Inhibit stimulation of beta-adrenergic receptors

Angiotensin-converting enzyme (ACE) inhibitors Inhibit formation of angiotensin II

Angiotensin II receptor blockers (ARBs) Inhibit binding of angiotensin II to type 1 angiotensin II Receptors

Vasodilators/Centrally actingDirect renin inhibitors

Special consideration in Antihypertensive Potential side effects

Thiazide diuretics should be used cautiously in gout or a history of significant hyponatremia.

BBs should be generally avoided in patients with asthma, reactive airways disease, or second- or third-degree heart block.

ACEIs should not be used in individuals with a history of angioedema. Aldosterone antagonists and potassium-sparing diuretics can cause

hyperkalemia.

Drug Treatment

Uncomplicated HypertensionThe 2009 updated European Society of Hypertension guidelines recommend initiating therapy in the elderly with thiazide diuretics, CAs, ACEIs, ARBs, or beta blockers based on a meta-analysis of major hypertension trials

Complicated HypertensionBeta blocker; CAD with hypertension and stable angina or prior

MI A long-acting dihydropyridine CA : in addition to the beta

blocker when the BP remains elevated or if angina persists.An ACEI should also be given, particularly if LV ejection fraction

is reduced and/or if HF is present.

Drug Treatment

• Angina; verapamil SR–trandolapril strategy.

• Acute coronary syndromes, beta blockers and ACEI, with additional drugs added as needed for BP control.

• Verapamil and diltiazem should not be used with significant LV systolic dysfunction or conduction system

• Beta blockers with intrinsic sympathomimetic activity must not be used after MI.

• Considerations for Drug Therapy, Great caution on alterations in drug distribution and disposal and changes in homeostatic CV control, as well as QoL factors

• Initiation of Drug Therapy

Start at the lowest dose and gradually Target 140 mm Hg, if tolerated, (< 80 year )

Drug Treatment

• Rapid initial reduction of BP within the first 3 months of therapy is required to improve cardiovascular outcomes

Do not go too low

• ACCORD BP (Action to Control Cardiovascular Risk in Diabetes Blood Pressure) trial found no additional benefit; target SBP 120 mm Hg versus a target of 140 mm Hg.

• INVEST (International VErapamil SR/Trandolapril Study) extended follow-up, diabetes cohort, suggest an increase in mortality when on-treatment SBP is 115 mm Hg or DBP 65 mm Hg.

• Some guidelines recommend reducing BP to 130/80 mm Hg in CAD patients, there is limited evidence to support this lower target in elderly patients with CAD.

• Observational data show the nadir BP for risk (CAD) was: 135/75 mm Hg for 70 to 80 years of age 140/70 mm Hg for 80 years of age.

Benefits of Treating Hypertension

Younger than 60 (reducing BP 10/5-6 mmHg) reduces the risk of stroke by 42% reduces the risk of coronary event by 14%

Older than 60 (reducing BP 15/6 mmHg) reduces overall mortality by 15% reduces cardiovascular mortality by 36% reduces incidence of stroke by 35% reduces coronary artery disease by 18%

Older than 60 with isolated systolic hypertension (SBP 160 mm Hg and DBP <90 mm Hg) 42% reduction in the risk of stroke 26% reduction in the risk of coronary events

Lancet 1990;335:827-38Arch Fam Med 1995;4:943-50

Hypertension in the Very Elderly Trial (HYVET)

• The first prospective trial in patients with hypertension >80 years of age

• Goal <150 mmHg prevent fatal and nonfatal events (incidence of nonfatal cardiovascular events—in particular of stroke—but not cardiovascular death)

• Diuretic (indapamide) + ACE-inhibitor (perindopril)

Routine Laboratory TestsPreliminary Investigations of patients with hypertension

1. Urinalysis2. Blood chemistry (potassium, sodium and creatinine)3. Fasting glucose4. Fasting total cholesterol and high density lipoprotein cholesterol

(HDL), low density lipoprotein cholesterol (LDL), triglycerides5. Standard 12-leads ECG

Currently there is insufficient evidence to recommend routine testing of microalbuminuria in people with hypertension who do not have diabetes

Abnormal Urinary Albumin levels

SettingUrinary albumin / creatinine level (mg/mmol)

Men Women

Chronic kidney Disease >30

Diabetes >2 >2.8

Emberson et al. Eur Heart J. 2004;25:484-491

10% Reduction

in BP

10% Reductio

nin Total-

C

+45%

Reduction

in CVD

=

90% of Hypertensive Canadians have other Cardiovascular Risk factors