Resistant Hypertension in People With CKD: A Review

RH has been redefined as BP that has been confirmed by out-of-office BP measurement to exceed the individualized BP target despite adherence to at least 3 maximally dosed antihypertensives, ideally including a diuretic. The prevalence of true RH is unknown and is likely lower than reported, but more common in patients with CKD. Evaluation of patients with apparent treatment resistance includes an assessment of and reduction in barriers to medication adherence. Screening for PA is a necessary step in evaluation, and other causes of secondary hypertension should be considered. Treatment of RH begins with addressing lifestyle factors that contribute to disease resistance, including interfering medications, dietary sodium intake, physical activity, obesity, and OSA. For patients with CKD, escalation of diuretic therapy is essential for BP reduction in patients who are volume expanded. When a fourth-line antihypertensive is necessary, aldosterone antagonists are preferred. Novel therapeutic devices need additional exploration before routine use in clinical practice.