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Hypertension is present in 40% of patients with a glomerular filtration rate (GFR) of 60 90 mL/min, and 75% of patients with a GFR < 30 mL/min Many factors play a role in the hypertension of renal failure, including volume; the reninangiotensin system; renal artery disease; activation of the sympathetic nervous system; and increased arterial stiffness and changes in vasoactive mediators, such as prostaglandins, endothelin, and parathyroid hormone ACE inhibitors and ARBs have been shown to delay progression of renal impairment in persons with type 1 and type 2 diabetes, respectively It is also likely that inhibition of the renin-angiotensin system protects renal function in nondiabetic renal disease associated with significant proteinuria As discussed above, hypertension should be treated until blood pressure reaches < 130/80 mm Hg in patients with chronic kidney disease There is a lack of definitive data to show that this level of blood pressure control slows the decline of GFR in persons with hypertensive chronic kidney disease without high-grade proteinuria However, since all patients with chronic kidney disease are at high risk for cardiovascular damage, treatment of blood pressure to the < 130/80 mm Hg target is appropriate, and interruption of the renin-angiotensin system would seem a reasonable approach Evidence has demonstrated that ACE inhibitors remain protective and safe in renal disease associated with significant proteinuria and serum creatinine as high as 5 mg/dL Note that such treatment would likely result in acute worsening of renal function in patients with significant renal artery stenosis, so renal function and electrolytes should be monitored carefully after introduction of ACE inhibitors In any event, use of ACE inhibitor/ARB therapy in the face of hyperkalemia is probably not warranted, since other antihypertensive medications are renoprotective as long as goal blood pressures are maintained

Substantial evidence indicates that blacks are not only more likely to become hypertensive and more susceptible to the cardiovascular complications of hypertension they also respond differently to many antihypertensive medications This may reflect genetic differences in the cause of hypertension or the subsequent responses to it, differences in occurrence of comorbid conditions such as diabetes or obesity, or

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Khan NA et al The 2006 Canadian Hypertension Education Program recommendations for the management of hypertension: Part II - Therapy Can J Cardiol 2006 May 15;22(7): 583 93 [PMID: 16755313] Lee JK et al Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial JAMA 2006 Dec 6;296(21):2563 71 [PMID: 17101639] Lindholm LH et al Should beta blockers remain first choice in the treatment of primary hypertension A meta-analysis Lancet 2005 Oct 29 Nov 4;366(9496):1545 53 [PMID: 16257341] Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) JAMA 2002 Dec 18;288(23):2981 97 [PMID: 12479763] Papademetriou V et al Stroke prevention with the angiotensin II type 1-receptor blocker candesartan in elderly patients with isolated systolic hypertension: the Study on Cognition and Prognosis in the Elderly (SCOPE) J Am Coll Cardiol 2004 Sep 15;44(6):1175 80 [PMID: 15364316] Rahman M et al Renal outcomes in high-risk hypertensive patients treated with an angiotensin-converting enzyme inhibitor or a calcium channel blocker vs a diuretic: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Arch Intern Med 2005 Apr 25;165(8):936 46 [PMID: 15851647] Sehgal AR Overlap between whites and blacks in response to antihypertensive drugs Hypertension 2004 Mar;43(3):566 72 [PMID: 14757779] Turnbull F et al; Blood Pressure Lowering Treatment Trialists Collaboration Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials Arch Intern Med 2005 Jun 27; 165(12):1410 9 [PMID: 15983291] Williams B The year in hypertension J Am Coll Cardiol 2006 Oct 17;48(8):1698 711 [PMID: 17045909] Wright JT Jr et al; ALLHAT Collaborative Research Group Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril JAMA 2005 Apr 6;293(13):1595 608 [PMID: 15811979].

Improper blood pressure measurement Volume overload and pseudotolerance Excess sodium intake Volume retention from kidney disease Inadequate diuretic therapy Drug-induced or other causes Nonadherence Inadequate doses Inappropriate combinations Nonsteroidal anti-inflammatory drugs; cyclooxygenase-2 inhibitors Cocaine, amphetamines, other illicit drugs Sympathomimetics (decongestants, anorectics) Oral contraceptives Adrenal steroids Cyclosporine and tacrolimus Erythropoietin Licorice (including some chewing tobacco) Selected over-the-counter dietary supplements and medicines (eg, ephedra, ma huang, bitter orange) Associated conditions Obesity Excess alcohol intake Identifiable causes of hypertension (see Table 11 2) Source: Chobanian AV et al The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report JAMA 2003 May 21;289(19):2560 72

Hypertensive emergencies have become less frequent in recent years but still require prompt recognition and aggressive but careful management A spectrum of urgent presentations exists, and the appropriate therapeutic approach varies accordingly Hypertensive urgencies are situations in which blood pressure must be reduced within a few hours These include patients with asymptomatic severe hypertension (systolic blood pressure > 220 mm Hg or diastolic pressure > 125 mm Hg that persists after a period of observation) and those with optic disk edema, progressive target organ complications, and severe perioperative hypertension Elevated blood pressure levels alone in the absence of symptoms or new or progressive target organ damage rarely require emergency therapy Parenteral drug therapy is not usually required, and partial reduction of blood pressure with relief of symptoms is the goal Hypertensive emergencies require substantial reduction of blood pressure within 1 hour to avoid the risk of serious morbidity or death Although blood pressure is usually strikingly elevated (diastolic pressure > 130 mm Hg), the correlation between pressure and end-organ damage is often poor It is the latter that determines the seriousness of the emergency and the approach to treatment Emergencies include hypertensive encephalopathy (headache, irritability, confusion, and altered mental status due to cerebrovascular spasm), hypertensive nephropathy (hematuria, proteinuria, and progressive renal dysfunction due to arteriolar necrosis and intimal hyperplasia of the interlobular arteries), intra-

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