In written comments to Pharmacy Times, Parminder K. Judge, PhD, MBChB, MRCP, associate professor at Oxford Population Health and honorary consultant nephrologist at Oxford University Hospitals, discussed monitoring patients with chronic kidney disease (CKD) whose blood pressure (BP) treatment is intensified. Judge is the corresponding author of a JAMA Cardiology meta-analysis that Pharmacy Times previously reported found that intensive BP control cuts cardiovascular (CV) risk regardless of CKD status.1,2
The meta-analysis of 27 trials found that intensive BP lowering did not increase kidney failure but did increase sustained declines in estimated glomerular filtration rate (eGFR), which the authors suggested may reflect hemodynamic responses to added diuretic therapy.1,2
Building on those findings, Judge said decisions to target a systolic BP below 120 mm Hg should be personalized, as that target would not be appropriate for all patients with CKD. When regimens are intensified, clinicians should monitor BP and symptoms that might be related to low BP, such as dizziness or light-headedness when standing. Particularly when diuretics are used, eGFR and electrolytes should also be monitored, because kidney function may drop due to the hemodynamic effect of lowering BP.
Judge said an eGFR decline after intensification could be a hemodynamic effect or a clinically meaningful decline, depending on the size of the drop from the patient’s baseline. Such changes need not automatically lead to reduction or withdrawal of therapy, she said, but should be managed carefully and holistically in the context of the patient’s clinical condition, medical history, and kidney function.
