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Hypertension 17 CHAPTER Hypertension 17 Sally Campoy ypertension is defined as blood pressure greater than Key Concepts H140/90 mmHg based upon the average of two or more measured readings at each of two or more office visits after 1. High blood pressure is the second leading cause of an initial screen (James et al., 2014). High blood pressure chronic kidney disease (CKD) requiring kidney replace - (BP) is the leading modifiable risk factor for cardiovascular ment therapy (KRT) in the United States, making up disease, kidney disease, and stroke. It is the one of the most about 25% of all cases. Hypertension is prevalent across common reasons for adult office visits to clinicians and for the entire CKD continuum including kidney transplant. use of prescription drugs. 2. Hypertension is the result of sustained elevated The National Health and Nutrition Examination Survey pressure over time that is associated with vascular (NHANES) data from 2007 to 2008 identified a 28% to 30% constriction, vascular remodeling, and structural prevalence of hypertension in the 18-years-and-older pop - changes that lead to increased vascular resistance. ulation of the United States, which estimates to approxi - 3. Risk factors that have a strong association with mately 65 million hypertensives in the adult population in developing hypertension include advancing age, the United States (Egan, Zhao, & Axon, 2010). While the genetics, diabetes, hyperlipidemia, and the modifiable prevalence of high blood pressure has increased when com - dietary and lifestyle risk factors of high sodium diet, pared to prevalence rates in the 1988 –1994 NHANES–III excessive alcohol use, obesity, and physical inactivity. data, it has remained unchanged since 2000, according to 4. The prevalence of hypertension in patients on successive NHANES findings (CDC, 2015; Egan et al., 2010; peritoneal dialysis is less than hemodialysis. Improved Yoon, Burt, Louis, & Carroll, 2012). fluid control related to more frequent dialysis Health and social disparities exist in the identification, contributes to better blood pressure control. treatment, and control of hypertension. Data estimates that 5. Management of hypertension begins with a trial of approximately 8% of U.S. adults have undiagnosed hyper - lifestyle modifications. Drug therapy should be started if tension with higher percentage of undiagnosed and uncon - the systolic blood pressure remains above 140 mmHg in patients younger than 60 years or above 150 mmHg in trolled hypertension among non-Hispanic Blacks and patients 60 years and older or if the diastolic pressure Mexican Americans (Yoon et al., 2015). remains above 90 mmHg after a trial of lifestyle While hypertension awareness, treatment, and control modifications. have increased over the years, only half of adults with hyper - 6. The choice of drug for first-line therapy is determined by tension controlled their blood pressure at less than140/90 in the desired degree of blood pressure reduction, patient 2009 –2010 (Yoon et al., 2012), which does not meet the characteristics, and preexisting conditions, as well as Healthy People 2020 goal of 62.1% (Egan et al., 2010; Office current clinical guideline evidence of decreased of Disease Prevention and Health Promotion, 2010). Uncon - cardiovascular risk, drug efficacy, safety, and tolerability. trolled hypertension rates among treated adults remains at 7. Special considerations for blood pressure management 30%, which are seen in those who are older, males, non-His - of the patient on hemodialysis include achievement of panic Blacks, Hispanics, and those with other comorbidities, dry weight status, timing of administration of such as diabetes mellitus, kidney disease, and obesity (Egan antihypertensive agents in relation to the dialysis et al., 2011; Wang & Vasan, 2005). treatment, dialyzability of the drug, and intradialytic Hypertension is the second leading cause of chronic kid - blood pressure changes as a result of ultrafiltration. ney disease (CKD) requiring kidney replacement therapy 8. Use of ambulatory blood pressure monitoring has (KRT) in the United States, making up approximately 25% become the gold standard to confirm hypertension in of all cases (USRDS, 2015). It is also a complication of CKD dialysis patients. This monitoring allows for assessment and associated with faster rates of progression in people with of blood pressure over time, correlating better with left diabetes and/or proteinuria when blood pressure is uncon - ventricular hypertrophy and all-cause mortality. trolled (KDIGO, 2013). High blood pressure is prevalent CHAPTER Cardiorenal and Hepatorenal Syndromes 22 Cynthia L. Russell • Dana Aholt Key Concepts Cardiorenal Syndrome 1. To decrease inconsistency and confusion, the Acute Dialysis Quality Initiative (ADQI) defines cardiorenal syndrome as disorders of the heart and kidneys, whereby acute or chronic dysfunction in one organ may Cardiorenal syndrome (CRS) is a comprehensive term that induce acute or chronic dysfunction of the other. describes the interaction of many diseases related to both the 2. Cardiorenal syndrome (CRS) is classified into five heart and the kidney. Whether the original source is cardiac subtypes, which designate the originating organ or kidney dysfunction, the result is a condition known as car - dysfunction and also categorize according to the acute diorenal syndrome (Ronco & DiLullo, 2014). Cardiac disease or chronic nature of the organ dysfunction. can often lead to deteriorating kidney function; the opposite 3. Type 1 CRS most often appears in acute decompensated is also true, whereby decreased kidney function leads to car - heart failure, and patients may present with four diac dysfunction or disease. Diseases of the heart and kidney different hemodynamic profiles termed wet or dry (the are singularly common within our population and often co - degree of perfusion) and warm or cold (the degree of exist, leading to significant morbidity and mortality. As di - congestion). agnosis and treatment can be long and complex, the cost of 4. Type 3 CRS pathophysiology is related to the cause of care can also be significant (House et al., 2010). the acute kidney injury (AKI), such as contrast-induced AKI, drug-induced AKI, major surgery, cardiac surgery, rhabdomyolysis, and postobstructive uropathy. Definition 5. Biomarkers, objectively measured and evaluated indicators specific to heart failure and kidney injury, are A consensus definition was developed to decrease inconsis - increasingly important in diagnosing CRS. tency and confusion as well as to develop multidisciplinary 6. Hepatorenal syndrome (HRS) is defined as acute kidney approaches to identification and treatment. A collaborative injury in the presence of either acute liver failure or conference, Acute Dialysis Quality Initiative (ADQI), with chronic liver disease, where there is no identifiable leading experts in nephrology, critical care, cardiac surgery, cause of the kidney injury. cardiology, and epidemiology, resulted in a common defini - 7. HRS is classified into two types. Type 1 involves rapid tion and classification term of cardiorenal syndromes . The deterioration in kidney function with a relatively graver term was defined as “disorders of the heart and kidneys prognosis than type 2, which tends to present with a whereby acute or chronic dysfunction in one organ may in - steady but moderate deterioration in kidney function. duce acute or chronic dysfunction of the other” (House et 8. HRS may be caused by bacterial infections, diarrhea and al., 2010, p. 1418). vomiting, diuretics, gastrointestinal bleeding, or large- In addition, five subtypes of the cardiorenal syndromes volume paracentesis without adequate blood volume were identified and defined: acute cardiorenal syndrome expansion. Half of the cases of HRS are spontaneous. (type 1), chronic cardiorenal syndrome (type 2), acute reno - 9. Liver transplantation is an option for treating HRS. ADQI cardiac syndrome (type 3), chronic renocardiac syndrome recommendations are for liver transplant alone for type (type 4), and secondary cardiorenal syndrome (type 5) 1 HRS less than 4 weeks in duration, and combination (House et al., 2010). The updates in the definition and clas - liver –kidney transplant for those at risk for nonrecovery sification system allowed a more unified approach to devel - of kidney function. opment of prevention and therapeutic strategies that may reduce organ damage (Ronco & Ronco, 2012). CHAPTER Depression in Chronic Kidney Disease 25 Carol S. Lieser epression is one of the most common mental health Key Concepts Ddisorders in the world. Defined as a feeling of sadness or sense of loss of enjoyment and pleasure, one of these two 1. Depression is the most common psychiatric disorder in characteristics combines with various somatic and cognitive patients with chronic kidney disease (CKD) and occurs at problems that affect the person’s ability to function (Amer - a rate four times greater than in those without any ican Psychiatric Association [APA], 2013). medical conditions. The reported prevalence rates of According to the National Institute of Mental Health depression in patients with CKD range from 21.4% to (NIMH), in 2013, an estimated 15.7 million adults ages 18 26.5% in stages 1 –4 and 22.8% to 39.3% in stage 5. or older in the United States had at least one major depressive 2. The causes of depression are considered to be one-third episode in the past year (NIMH, 2013). This represented genetic and two-thirds environmental. No single
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