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In the Clinic |

Chronic Kidney Disease

Paul Drawz, MD, MHS, MS; and Mahboob Rahman, MD, MS
[+] Article, Author, and Disclosure Information

CME Objective: To review current evidence for screening, and prevention, diagnosis, treatment, and practice improvement of chronic kidney disease.

Funding Source: American College of Physicians.

Disclosures: Drs. Drawz and Rahman, ACP Contributing Authors, have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2715.

With the assistance of additional physician writers, Annals of Internal Medicine editors develop In the Clinic using resources of the American College of Physicians, including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program).


Ann Intern Med. 2015;162(11):ITC1. doi:10.7326/AITC201506020
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This issue provides a clinical overview of chronic kidney disease, focusing on prevention, diagnosis, treatment, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Figures

Grahic Jump Location
Figure.

Stage of chronic kidney disease by GFR and albuminuria categories.

GFR and albuminuria categories inform the risk for progression. Green indicates low risk, yellow indicates moderately increased risk, orange indicates high risk, and red indicates very high risk. The numbers in each box are recommendations for the frequency of monitoring/year. GFR = glomerular filtration rate. From reference (12), with permission.

Grahic Jump Location

Tables

References

Letters

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Comments

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Blood pressure control reduces progression of chronic kidney disease (CKD) to end stage renal disease (ESRD)
Posted on September 15, 2015
Gauranga Dhar
Bangladesh Institute of Family Medicine and Research
Conflict of Interest: None Declared
As stated in the article “However, although treating hypertension reduces the risk for cardiovascular events, reducing blood pressure does not reduce the risk for CKD”. I cannot agree with this statement.
Diabetes and hypertension are the most common causes of chronic kidney disease (CKD) and can be named as diabetic and hypertensive nephropathy respectively. Uncontrolled hypertension is a risk factor for developing and more rapid progression of CKD and the second leading cause of ESRD [1]. On the other hand progression of CKD may exacerbate hypertension due to increased systemic vascular resistance and volume expansion. Number of guidelines discusses the importance of adequate blood pressure control to reduce progression of CKD [2-3].
Uncontrolled blood pressure increases intraglomerular pressure, damage to glomeruli, impairment in glomerular filtration and subsequent increase in urinary protein secretion which may be considered as the first sign of CKD [4]. This also may be considered as one of the pathogenetic factors of reduction of glomerular filtration rate (GFR).
Still there are controversies about the optimal blood pressure goal in patients with CKD. Although some trials have failed to prove the differences in reduction of cardio-renal outcomes in patients with blood pressure goals at <130/80mmHg compared to <140/90mmHg, lower blood pressure goal e.g. <130/80mmHg has been found to reduce CKD progression in patients with CKD associated with proteinuria [5].
A recent, NIH funded SPRINT (systolic blood pressure intervention trial) study which even compared more aggressive systolic blood pressure control e.g. <120mmHg compared to <140mmHg to reduce cardio-renal outcomes. Although the study was supposed to go until 2017 but was sopped pre-maturely after seeing the cardio-renal benefit of aggressive systolic blood pressure control, <120mmHg compared to <140mmHg.
In conclusion, I think adequate blood pressure control may reduce both cardiovascular and renal outcomes including reduction of CKD progression. Blood pressure control should be individualized according to the burden of proteinuria.



References:
1. Botdorf J, Chaudhary K, Whaley-Connell A. Hypertension in cardiovascular and kidney disease. Cardiorenal Med. 2011;1:183–192.
2. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(suppl 1):S1-S266.
3. American Diabetes Association. Standards of medical care in diabetes–2012. Diabetes Care. 2012;35(suppl 1):S1-S63.
4. Keane WF, Eknoyan G. Proteinuria, albuminuria, risk, assessment, detection, elimination (PARADE): a position paper for the National Kidney Foundation. Am J Kidney Dis. 1999;33:1004–1010.
5. Upadhyay A, Earley A, Haynes SM, Uhlig K. Systematic review: blood pressure target in chronic kidney disease and proteinuria as an effect modifier. Ann Intern Med. 2011;154:541–548.
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