Published online Dec 25, 2023. doi: 10.5527/wjn.v12.i5.168
Peer-review started: August 20, 2023
First decision: September 14, 2023
Revised: September 20, 2023
Accepted: October 23, 2023
Article in press: October 23, 2023
Published online: December 25, 2023
Processing time: 123 Days and 13.9 Hours
Hypertension is a major contributor towards the progression of chronic kidney disease (CKD) and a leading consequence of CKD. Despite standard guidelines, clinician practices on managing hypertension in CKD patients remain variable.
It is important to explore the factors relating to CKD patients that influences a clinician’s decision to use specific antihypertensive agents with the aim to better standardize current antihypertensive prescription practices.
To investigate hypertension management practices in CKD patients within a real-world setting.
We retrospectively analysed patients recruited into the Salford Kidney Study database. Data including patient demographic information, comorbidities, and a detailed antihypertensive medication history were reviewed. Prescription patterns of antihypertensive agents were explored based on estimated glomerular filtration rate expressed as mL/min/1.73 m2, urine albumin-creatinine ratio, primary kidney disease aetiology, and cardiovascular disease. The association between being prescribed three or more antihypertensive agents and clinical outcomes (i.e. all-cause mortality and reaching end stage kidney disease) was also studied.
A total of 3230 non-dialysis dependent CKD patients with data collected between October 2002 and December 2019 were included. The most frequently prescribed antihypertensive agents were renin angiotensin system blockers (61%), followed by diuretics (47%), dihydropyridine calcium channel blockers (39%), and beta blockers (34%). A greater proportion of patients were taking three or more antihypertensive agents with advancing CKD stages (53% of CKD stage 5 patients vs 26% of CKD stage 2 patients) and as the urine albumin-creatinine ratio increased (category A3: 62% vs category A1: 40%, P < 0.001). The prescription of three or more antihypertensive agents was associated with all-cause mortality, independent of blood pressure control (hazard ratio: 1.15; 95% confidence interval: 1.04-1.27, P = 0.006).
Renin angiotensin system blockers were found to be the most prescribed antihypertensive agents, followed by diuretics and calcium channel blockers. Outcomes were poorer in CKD patients with poor blood pressure control despite being on multiple antihypertensive agents.
Our study results aligned with expectations from the current National Institute of Health and Care Excellence guideline algorithm; further work determining optimal strategies in approaching antihypertensive prescriptions for CKD patients at both an individual and policy level is needed to reduce the variations currently observed in clinical practice.