만성콩팥병환자에서의혈압관리 분당서울대병원신장내과 안신영

만성콩팥병환자에서의혈압관리 분당서울대병원신장내과 안신영

Contents Introduction Lifestyle and Pharmacological Tx CKD ND ptswithout diabetes CKD ND ptswith diabetes In elderly ptswith CKD ND 2013 대한고혈압학회진료지침 JNC 8th

Introduction Chronic kidney disease (CKD) and hypertension (HTN) Strong association btw CKD and high blood pressure (BP) Each can cause and aggravate the other

Introduction BP control in CKD patients Fundamental to the care of patients with CKD Slow progression to ESRD Reduce cardiovascular morbidity and mortality

KDIGO 2012 guideline The 2012 KDIGO clinical practice guideline aims to provide guidance on BP management and treatment for all non-dialysisdependent CKD patients and kidney transplant recipients. Populations of interest Adults with CKD ND (non-dialysis-dependent) without diabetes Adults with CKD ND with diabetes Adults with CKD ND who have received a kidney transplant Children with CKD ND Elderly with CKD ND

Relationship among categories for albuminuria and proteinuria

Introduction The strength of recommendation Level 1 ( We recommend ) Most patients should receive the recommended course of action Level 2 ( We suggest ) Different choices will be appropriate for different patients Each patient needs help to arrive at a management decision consistent with her or his values and preferences Not Graded Typically to provide guidance based on common sense or where the topic dose not allow adequate application of evidence

Introduction The quality of the supporting evidence

- Lifestyle and pharmacological treatment General strategies (not graded) 환자의나이, 동반질환, 만성신부전진행의가능성등을고려하여 혈압의목표를개별화하고적절한약제를선택한다. 주기적으로기립성어지럼증등의증상및저혈압발생여부에대해서평가한다. 고령, 자율신경기능장애를동반한당뇨환자의경우기립성저혈압의고위험군

- Lifestyle and pharmacological treatment 생활습관개선 건강체중유지 = BMI 20-25 (1D) 저염식이 : < 2 g/day of Na or < 5 g/day of NaCl (1C)

- Lifestyle and pharmacological treatment 생활습관개선 : 운동 : 30 minutes & 5 times/week (1D) 음주 : 남성 < 2 standard drinks/day, 여성 < 1 standard drinks/day (2D) Standard drinks : 8 19.7 g of alcohol (in different countries) 10g of alcohol = 100ml of wine, 285ml of full strength beer, 425ml of light beer

- Lifestyle and pharmacological treatment 고혈압약제 RAAS blockers : ACEi or ARB 적응증 : CKD with urinary albumin excretion 주의사항 : hyperkalemia, decreased GFR Risk factors - Renal atery stenosis - Volume depletion - NSAIDs or COX-2 inhibitor 등과병행사용

Case - F/65, DM for 10yrs - 24h urine protein 535 mg/day, BP : 140/90 mmhg, scr 1.0 mg/dl - Start ARB scr 1.3 mg/dl(2wks later) -?? ARB exerts desired action (intraglomerular pr ) Accept 20-30% increase in scr within 2wks of initiation Repeat scr 2-4 wks Stabilization : continue scr > 30% : dose by 50% & exclude hypovolemia, NSAIDs scr > 50% : stop ARB or ACEi & study of renal artery stenosis

- Lifestyle and pharmacological treatment Diruetics 만성콩팥병환자에서혈압상승의주된요인 : salt and water retention Thiazide Since 1950s Salt and water excretion 부종이있는 CKD 환자에서 1 or 2 번째항고혈압약제로많이사용 ACEior ARB 와함께처방 : hyperkalemia 의위험을낮춤 Loop diuretics Thiazide 보다는 short-term 으로사용 CKD stage 4-5 환자에서부종조절시 thiazide 보다많이사용

- Lifestyle and pharmacological treatment Beta blockers In CKD : Accumulation of beta-blockers or active metabolites exacerbate concentration-dependent side effects : bradycardia ex) atenolol, bisoprolol (not carvedilol, propranolol, metoprolol) 적응증 CKD with heart failure : endorsed usage of beta-blocker CKD without heart failure : no evidence on direct efficacy to mortality

- Lifestyle and pharmacological treatment Calcium channel blocker 3 subclasses Dihydropyridines - amlodipine, nifedipine, lercanidipine : more selective for vascular smooth muscle (vasodilatation) Non-dihydropyridine benzothiazepines diltiazem Phenylalkylamines verapamil Do not acculmate in patients with impaired kidney functions Exception of nicardipine and nimodipine in elderly patients with CKD

- Lifestyle and pharmacological treatment Calcium channel blocker 적응증 Widely used in HTN, angina, supra-ventricular tachycardia Consideration Dihydropyridine : urinary albumin excretion 증가된환자에서사용하지않도록 Non-dihydropyridines ( 특히 ACEi/ARB 같이쓰지않는경우 ) beta-blocker (atenolol or bisoprolol 등 ) 과같이사용할경우 bradycardia 에주의 신장이식을받은환자에서 CNI, sirolimus 의 blood level 을높일수있으므로주의가 필요함

- In CKD ND patients without diabetes Urine albumin excretion < 30 mg/day (protein excretion < 150 mg/day) Office BP > 140 mmhg systolic or > 90 mmhg diastolic Treated with BP-lowering drugs to maintain a BP 140/90 mmhg (1B) Rationale High BP is a risk factor for CVD and development and progression of CKD Lowering BP in the general population reduces cardiovascular risk Lowering BP in CKD patients reduces the rate of CKD progression CKD is a major risk factor for CVD

- In CKD ND patients without diabetes Urine albumin excretion 30~300 mg/day (protein excretion 150~500 mg/day) Office BP > 130 mmhg systolic or > 80 mmhg diastolic Treated with BP-lowering drugs to maintain a BP 130/80 mmhg (2D) ARB or ACEi(2D) Urine albumin excretion > 300 mg/day (protein excretion > 500 mg/day) Office BP > 130 mmhg systolic or > 80 mmhg diastolic Treated with BP-lowering drugs to maintain a BP 130/80 mmhg (2C) ARB or ACEi(1B)

- In CKD ND patients without diabetes Rationale Microalbuminuriaand macroalbuminuria are major risk factors for CVD and CKD progression RCTs suggest that a BP 130/80 mmhg may reduce progression of CKD in patients with albuminuria

-In CKD ND patients with diabetes Urine albumin excretion < 30 mg/day (protein excretion < 150 mg/day) Office BP > 140 mmhg systolic or > 90 mmhg diastolic Treated with BP-lowering drugs to maintain a BP 140/90 mmhg (1B) Rationale RCTs and observational studies have been consistent in suggesting that lowering BP so that it is consistently < 140/90 mmhg will prevent major cardiovascular events. Lowering BP to these levels is also likely to reduce the risk of progressive CKD The evidence for the benefit of further lowering of the BP target is mixed

-In CKD ND patients with diabetes Urine albumin excretion > 30 mg/day (protein excretion > 150 mg/day) Office BP > 130 mmhg systolic or > 80 mmhg diastolic Treated with BP-lowering drugs to maintain a BP 130/80 mmhg (2D) Rationale Observational studies :The level of urine albumin predicts the risk of adverse cardiovascular and kidney outcomes BP lowering reduces the rate of urinary albumin excretion, which may lead to a reduced risk of both kidney and cardiovascular events ARB or ACEi(2D)

-In CKD ND patients with diabetes Urine albumin excretion > 300 mg/day Office BP > 130 mmhg systolic or > 80 mmhg diastolic Treated with BP-lowering drugs to maintain a BP 130/80 mmhg ARB or ACEi(1B)

-In elderly patients with CKD ND Elderly : 65 years of age Tailor BP treatment considering age, co-morbidities and other therapies, with gradual escalation of treatment Close attention to adverse events related to BP treatment, including electrolyte disorders, acute deterioration in kidney function, orthostatic hypotension and drug side effects (Not Graded)

2013 대한고혈압학회진료지침 만성콩팥병과고혈압 혈압조절의목표는당뇨병의동반여부와무관함 목표혈압 알부민뇨없는만성콩팥병 : < 140/90 mmhg 알부빈뇨동반시 : < 130/80 mmhg 알부민뇨가동반되었을때 : 우선적으로 ACEi/ARB 제재를사용

JNC 8th

Summary Albuminuria A1 (UACR <30mg/g) A2 (UACR 30-300 mg/g) A3 (UACR > 300 mg/g) Non diabetes 140/90 (1B) 130/80 (2D) 130/80 (2C) Diabetes 140/90 (1B) 130/80 (2D) 130/80 (2D) Elderly Tailor BP treatment (Not Graded) CKD ND and urine albumin excretion 30-300 mg/day : ARB or ACEi (2D) CKD ND and urine albumin excretion > 300 mg/day : ARB or ACEi (1B)

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