Kidney disease, chronic goals

Goal BP values are <140/90 for most patients, but <130/80 for patients with diabetes mellitus, significant chronic kidney disease, known coronary artery disease (myocardial infarction [MI], angina), noncoronary atherosclerotic vascular disease (ischemic stroke, transient ischemic attack, peripheral arterial disease [PAD], abdominal aortic aneurysm), or a 10% or greater Framingham 10-year risk of fatal coronary heart disease or nonfatal MI. Patients with LV dysfunction have a BP goal of <120/80 mm Hg. 

A goal BP of less than 140/90 mm Hg is appropriate for most patients. Achieving lower BP values has not been proven to provide additional risk reduction, except in patients with diabetes or chronic kidney disease. These patients have a goal BP of less than 1 30/80 mm Hg. 

For patients with diabetes mellitus or chronic kidney disease, values >1 30/80 mm Hg are considered above goal. 

After a dehnitive diagnosis of hypertension is made, patients should be placed on both lifestyle modihcations and drug therapy concurrently. Lifestyle modihcation alone is considered appropriate therapy for patients with prehypertension. However, lifestyle modifications alone are not considered adequate for patients with hypertension or patients with BP goals of less than 130/80 mm Hg (those with diabetes and chronic kidney disease) who have BP values above their goal. 

Patients with hypertension may develop damage to either the renal tissue (parenchyma) or the renal arteries. Chronic kidney disease presents initially as microalbuminuria (30-299 mg albumin in a 24-hour urine collection) that can progress to macroalbuminuria and overt kidney failure. The rate of kidney function deterioration is accelerated when both hypertension and diabetes are present. Once patients have an estimated glomerular filtration rate (GFR) of less than 60 mL/m per minute or macroalbuminuria, they have chronic kidney disease, and the risk of cardiovascular disease and progression to severe chronic kidney disease increases. Strict BP control to a goal of less than 130/80 mm Hg can slow the decline in kidney function. This strict control often requires two or more antihypertensive agents. 

Starting therapy with a combination of two drugs is now recommended in patients far from their BP goal, for patients in whom goal achievement may be difficult (i.e., those with diabetes or chronic kidney disease and African-Americans), or in patients with multiple compelling indications for different antihypertensive agents. However, combination therapy is often needed to control BP in patients already on therapy, and most patients reqnire two or more agents. ° °... 

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