Adults with CKD may not reach BP needed to reduce cardiorenal complication risk
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Key takeaways:
- Researchers observed a rate of prescription change of 50 per 100 person-years.
- Prescription changes were influenced by clinician preference and patient tolerability.
Reaching an appropriate blood pressure target is key to lowering risks for cardiorenal complications, but many patients with chronic kidney disease may be unable to do so, prospective study data show.
“Hypertension is the leading modifiable risk factor for premature death, affecting 1.4 billion people worldwide. A possible cause and consequence of CKD, hypertension is also its most common comorbidity. Strict BP control unambiguously improves survival and cardiovascular outcomes in this population,” Margaux Costes-Albrespic, MPH, a doctoral student at the Centre for Research in Epidemiology and Population Health, Paris-Saclay University in France, wrote with colleagues. However, “[recommended] targets are not met by many patients, with considerable international variation,” they wrote.
Patients from the CKD-Renal Epidemiology and Information Network cohort study, conducted from 2013 to 2016 at 40 French nephrology clinics, were observed in the trial. Researchers identified 2,755 patients receiving nephrology care who had hypertension and CKD stages 3 through 4. Patient and provider factors, such as sociodemographic traits, medical history and laboratory data, were also considered.
Median age at baseline was 69 years and mean eGFR was 33 mL/min/1.73 m2. Overall, 66% were men, 81% had a BP of at least 130/80 mm Hg and 75% were prescribed at least two antihypertensive medications.
The observational study aimed to assess longitudinal patterns of antihypertensive drug prescription and systolic BP during a of median 5 years. Outcomes included add-on, switch and withdrawal changes in antihypertensive drug classes prescribed during follow-up.
Patients were followed until kidney replacement therapy, completion of follow-up or 2020.
Researchers observed a rate of prescription change of 50 per 100 person-years, 23 per 100 for add-ons and 25 per 100 for withdrawals. In addition, the researchers found poor medication adherence was linked to a higher risk of add-on (HR = 1.35; 95% CI, 1.01-1.80), while a lower education level was linked to increased withdrawal risk (HR = 1.23; CI, 1.02-1.49).
Costes-Albrespic and colleagues highlighted that more frequent nephrologist visits (at least four vs. none) were associated with higher risks of both antihypertensive add-on and withdrawal (HR = 1.52; 95% CI, 1.06-2.18 and HR = 1.57; 95% CI, 1.12-2.19, respectively). On the other hand, associations with visit frequency to other physicians varied based on specialty.
Researchers also found that while mean systolic BP decreased by 4 mm Hg after drug add-on, it was infrequently maintained, and that and changes in antihypertensive prescriptions were common and often influenced by clinician preferences and patients' tolerability.
“Our findings further suggest that specialists and primary care physicians have different roles in prescribing and deprescribing drugs for CKD patients, which underlines the importance of coordinated care,” the researchers wrote. “Systolic BP decrease following add-on on an antihypertensive drug class in real-world seemed, however, modest, and little sustained in time, consistently with the high rates of withdrawal and frequent poor self-reported adherence in this population.”
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