Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California.
Clin J Am Soc Nephrol. 2022 Oct;17(10):1457-1466. doi: 10.2215/CJN.04110422. Epub 2022 Sep 9.
More intensive BP goals have been recommended for patients with CKD. We estimated the prevalence of apparent treatment-resistant hypertension among patients with CKD according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA; BP goal <130/80 mm Hg) and 2021 Kidney Disease Improving Global Outcomes (KDIGO; systolic BP <120 mm Hg) guidelines in two US health care systems.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We included adults with CKD (an eGFR <60 ml/min per 1.73 m) and treated hypertension from Kaiser Permanente Southern California and the Veterans Health Administration. Using electronic health records, we identified apparent treatment-resistant hypertension on the basis of () BP above the goal while prescribed three or more classes of antihypertensive medications or () prescribed four or more classes of antihypertensive medications regardless of BP. In a sensitivity analysis, we required diuretic use to be classified as apparent treatment-resistant hypertension. We estimated the prevalence of apparent treatment-resistant hypertension per clinical guideline and by CKD stage.
Among 44,543 Kaiser Permanente Southern California and 241,465 Veterans Health Administration patients with CKD and treated hypertension, the prevalence rates of apparent treatment-resistant hypertension were 39% (Kaiser Permanente Southern California) and 35% (Veterans Health Administration) per the 2017 ACC/AHA guideline and 48% (Kaiser Permanente Southern California) and 55% (Veterans Health Administration) per the 2021 KDIGO guideline. By requiring a diuretic as a criterion for apparent treatment-resistant hypertension, the prevalence rates of apparent treatment-resistant hypertension were lowered to 31% (Kaiser Permanente Southern California) and 23% (Veterans Health Administration) per the 2017 ACC/AHA guideline. The prevalence rates of apparent treatment-resistant hypertension were progressively higher at more advanced stages of CKD (34%/33%, 42%/36%, 52%/41%, and 60%/37% for Kaiser Permanente Southern California/Veterans Health Administration eGFR 45-59, 30-44, 15-29, and <15 ml/min per 1.73 m, respectively) per the 2017 ACC/AHA guideline.
Depending on the CKD stage, up to a half of patients with CKD met apparent treatment-resistant hypertension criteria.
对于慢性肾脏病（CKD）患者，建议将血压目标设定得更为严格。我们根据 2017 年美国心脏病学会/美国心脏协会（ACC/AHA；血压目标<130/80mmHg）和 2021 年肾脏病改善全球结局组织（KDIGO；收缩压<120mmHg）指南，在两个美国医疗保健系统中估计了 CKD 患者中明显的治疗抵抗性高血压的患病率。
设计、设置、参与者和测量：我们纳入了来自 Kaiser Permanente Southern California 和 Veterans Health Administration 的患有 CKD（eGFR<60ml/min/1.73m²）和治疗性高血压的成年人。通过电子健康记录，我们根据以下标准确定明显的治疗抵抗性高血压：（1）BP 高于目标值，同时服用三种或更多种降压药物；或（2）无论 BP 如何，服用四种或更多种降压药物。在一项敏感性分析中，我们要求利尿剂的使用将被归类为明显的治疗抵抗性高血压。我们根据每个临床指南和 CKD 分期来估计明显的治疗抵抗性高血压的患病率。
在 44543 名来自 Kaiser Permanente Southern California 和 241465 名来自 Veterans Health Administration 的患有 CKD 和治疗性高血压的患者中，根据 2017 年 ACC/AHA 指南，明显的治疗抵抗性高血压的患病率分别为 39%（Kaiser Permanente Southern California）和 35%（Veterans Health Administration），根据 2021 年 KDIGO 指南，这一比例分别为 48%（Kaiser Permanente Southern California）和 55%（Veterans Health Administration）。如果要求利尿剂作为明显的治疗抵抗性高血压的标准，那么根据 2017 年 ACC/AHA 指南，明显的治疗抵抗性高血压的患病率分别降至 31%（Kaiser Permanente Southern California）和 23%（Veterans Health Administration）。根据 2017 年 ACC/AHA 指南，明显的治疗抵抗性高血压的患病率随着 CKD 分期的进展而逐渐升高（Kaiser Permanente Southern California/Veterans Health Administration eGFR 45-59、30-44、15-29 和<15ml/min/1.73m²，分别为 34%/33%、42%/36%、52%/41%和 60%/37%）。
根据 CKD 分期，多达一半的 CKD 患者符合明显的治疗抵抗性高血压标准。
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