Management of hypertension in patients with CKD: differences between primary and tertiary care settings.
BACKGROUND
Although most patients with moderate chronic kidney disease (CKD) are managed exclusively in primary care (PC), no data on blood pressure (BP) control in this setting are available. We compared hypertension management in patients with CKD followed up in PC and nephrology tertiary care (TC).


METHODS
We studied hypertensive patients with estimated glomerular filtration rates (eGFRs) of 15 to 60 mL/min/1.73 m2 (0.25 to 1.00 mL/s) exclusively followed up for at least 1 year in PC (n = 259) or TC (n = 186).


RESULTS
PC compared with TC patients were characterized by older age (73 +/- 10 versus 65 +/- 14 years; P < 0.0001), greater prevalences of previous cardiovascular events (59% versus 32%; P < 0.0001) and diabetes (36% versus 23%; P = 0.005), and slightly greater eGFRs (37 +/- 10 versus 34 +/- 11 mL/min/1.73 m2 ; P = 0.005). They showed higher BP levels (143 +/- 15/82 +/- 7 versus 136 +/- 18/78 +/- 11 mm Hg; P < 0.0001), with a lower prevalence of BP target (5.8% [95% confidence interval (CI), 2.9 to 8.6] versus 21.5% [95% CI, 15.6 to 27.4]; P < 0.0001). The risk for not achieving BP target in PC was 2.6 times greater, independently from age, sex, diabetes, and eGFR. Fewer antihypertensive drugs were prescribed in PC (1.9 +/- 1.1 versus 2.5 +/- 1.1; P < 0.0001). In both groups, inhibitors of the renin-angiotensin system were the most frequently prescribed drugs (>84%), followed by diuretics (50%). However, family physicians almost exclusively prescribed hydrochlorothiazide, whereas nephrologists preferentially prescribed furosemide, administered at a higher dose than in PC (47 +/- 41 versus 28 +/- 21 mg/d; P = 0.004).


CONCLUSIONS
Control of CKD-related hypertension is significantly worse in PC despite a greater cardiovascular risk. Barriers to optimal BP control likely are represented by a low number of drugs and inadequate diuretic therapy.
Minutolo
Roberto
R
Department of Nephrology, Second University of Naples, Naples, Italy. roberto.minutolo@unina2.it
De Nicola
Luca
L
Zamboli
Pasquale
P
Chiodini
Paolo
P
Signoriello
Giuseppe
G
Toderico
Clemente
C
Arfè
Gennaro
G
Boschi
Giuseppe
G
Brancati
Ciro
C
Iaccarino
Patrizia
P
Conte
Giuseppe
G
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D047228:Angiotensin II Type 1 Receptor Blockers / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D002121:Calcium Channel Blockers / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000453:epidemiology; D019090:Case Management; D002908:Chronic Disease; D015331:Cohort Studies; D015897:Comorbidity; D003404:Creatinine / Q000097:blood; D004232:Diuretics / Q000627:therapeutic use; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D005665:Furosemide / Q000627:therapeutic use; D005919:Glomerular Filtration Rate; D006801:Humans; D006852:Hydrochlorothiazide / Q000627:therapeutic use; D006973:Hypertension / Q000188:drug therapy* / Q000209:etiology; D006977:Hypertension, Renal / Q000188:drug therapy / Q000209:etiology; D007558:Italy / Q000453:epidemiology; D007674:Kidney Diseases / Q000150:complications* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000379:methods* / Q000706:statistics & numerical data; D010044:Outpatient Clinics, Hospital / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000379:methods* / Q000706:statistics & numerical data; D012307:Risk Factors; D049993:Sodium Chloride Symporter Inhibitors / Q000627:therapeutic use; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D014505:Urban Population
D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D002121:Calcium Channel Blockers; D004232:Diuretics; D049993:Sodium Chloride Symporter Inhibitors; D006852:Hydrochlorothiazide; D005665:Furosemide; D003404:Creatinine