HYPERTENSION AND THE

KIDNEY
Linda Armelia

Blood Pressure Assessment:

Patient preparation and posture
Standardized Preparation:
Patient
1. No acute anxiety, stress or pain
2. No caffeine, smoking or nicotine in the preceding 30
minutes
3. No use of substances containing adrenergic stimulants
such as phenylephrine or pseudoephedrine (may be
present in nasal decongestants or ophthalmic drops).
4. Bladder and bowel comfortable
5. No tight clothing on arm or forearm
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before measurement
8. Patient should stay silent prior and during the procedure.

Blood Pressure Assessment:

Patient preparation and posture
Standardized technique:
Posture
The patient should be
calmly seated with his or
her back well supported
and arm supported at the
level of the heart.
His or her feet should
touch the floor and legs
should not be crossed.

Pendahuluan
Riskesdas 2007:
hipertensi di Indonesia mencapai 31,7 persen
dari populasi pada usia 18 tahun ke atas.
60% penderita hipertensi berakhir
penyakit stroke, dan sisanya mengalami
gangguan jantung, gagal ginjal dan kebutaan.
hipertensi sebagai penyebab kematian nomor
tiga setelah stroke dan tuberkulosis
Jumlahnya mencapai 6,8 % dari proporsi
penyebab kematian pada semua umur di
Indonesia.

Pengaturan Tekanan Darah

Faktor-faktor yang mengontrol Tekanan

Darah

Definisi

Circulation. 2000;102:IV-40
IV-45

European Society of Hypertension

Classification of Blood Pressure
Category

Systolic

Diastolic

Optimal

<120

and / or

<80

Normal

<130

and / or

<85

High-Normal

130-139

and / or

85-89

Grade 1 (mild hypertension )

140-159

and / or

90-99

Grade 2 (moderate hypertension)

160-179

and / or

100-109

Grade 3 (severe hypertension)

180

and / or

110

Isolated Systolic Hypertension (ISH)

140

and

<90

The category pertains to the highest risk blood pressure

*ISH=Isolated Systolic Hypertension.
J Hypertens 2007;25:110587

JNC VII (American) Classification

of Blood Pressure
Category

Systolic

Diastolic

Optimal

<120

and / or

<80

Normal

<130

and / or

<85

High-Normal

130-139

and / or

85-89

Stage 1 (mild hypertension )

140-159

and / or

90-99

Stage 2 (moderate to severe

hypertension)

160

and / or

100-109

Isolated Systolic Hypertension (ISH)

140

and

<90

The category pertains to the highest risk blood pressure

*ISH=Isolated Systolic Hypertension.
JAMA 2003;289:2560-72

Penyebab Hipertensi

Hipertensi Resisten
Refraktori
TD tidak tercapai setelah pemberian
regimen 3 obat yang adekuat termasuk
diuretik, 3 regimen tersebut mendekati
maksimal dosis
Perburukan TD pada GGK tanda progresi;
risiko tinggi volume-dependent
hypertension
Berkembang krisis hipertensi [>180/120
mm Hg] dengan atau tanpa penundaan
atau progresif disfunsgi organ

Evaluasi Hipertensi
Menilai gaya hidup
dan indentifikasi
faktor-faktor
kardiovaskular
prognosis dan
tatalaksana
Indentifikasi etiologi
Menilai ada atau
tidaknya kerusakan
organ dan penyakit
kardiovakular

Pemeriksaan Laboratorium
Awal terapi
EKG
Urinalisis, gula darah, hemotokrit,
kalium, kreatinin [eGFR], kalsium,
profil lipid
Lain: ekskresi albumin urin atau rasio
albumin/kreatinin

Identifikasi Penyebab
Hipertensi
Tes diagnostik terutama
usia, riwaayat perjalanan penyakit,
pemeriksaan fisik, tingkat keparahan
hipertensi, laboratorium abnormal
TD kurang respons dengan terapi yg
diberikan
TD mulai meningkat tanpa diketahui
penyebabnya setelah terkontrol dg baik
Awitan hipertensi timbul mendadak

Identifikasi Penyebab
Hipertensi
Renal artery stenosis and subsequent renovascular
hypertension dicuriga:
(1)awitan hipertensi usia <30 tahun, tidak ada
riwayat keluarga hipertensi, awitan hipertensi usia
> 55 tahun
(2)bruit abdominal terutama terdapat komponen
diastolik
(3) accelerated hypertension
(4) hipertensi awalnya mudah dikontrol resisten
(5) edema pulmonal berulang
(6) gagal ginjal dg etiologi belum jelas, terutama
tidak ada proteinuria

Rekomendasi Follow Up
Tekanan Darah

Target Terapi
Mencapai pengurangan maksimal risiko
jangka panjang penyakit kardiovaskular
TD <140/90 mmHg (systolik/diastolik)
Target TD <130/80 mmHg diabetes, risiko
tinggi: stroke, infark myocardial, disfungsi
ginjal, proteinuria
Agar lebih mudah mencapai tekanan darah
yang diinginkan terapi antihipertensi harus
dilakukan sebelum adanya kerusakan
kardiovaskular yg signifikan

Evaluasi Terapi Hipertensi

pada PGK

Complications of Hypertension:
End-Organ Damage
Hypertension
Hypertension

Hemorrhage,
Stroke

Retinopathy

LVH, CHD, CHF

Peripheral
Vascular
Disease

CHD = coronary heart disease

CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.

Renal Failure,
Proteinuria
Slide Source
Hypertension Online
www.hypertensiononline.org

Modifiable risks for developing

hypertension

Obesity
Poor dietary habits
High sodium intake
Sedentary lifestyle
High alcohol consumption

Modifikasi gaya hidup untuk pengendalian

Hipertensi
Modifikasi

Rekomendasi

Penurunan Tekanan
Darah Sistolik kurang
lebih

Menurunkan berat badan

Pelihara berat badan

normal (BMI 18.5-24.9)

5-20 mm Hg utk
setiap penurunan 10
kg BB

Menjalankan menu DASH

Konsumsi makanan kaya

buah, sayur, susu
rendah lemak dan
rendah lemak jenuh

8-14 mm Hg

Mengurangi asupan
garam/sodium

Kurangi natrium sampai

tidak lebih dari 2.4
g/hari atau NaCl 6
g/hari

2-8 mm Hg

Meningkatkan aktifitas
fisik

Berolahraga erobik
teratur seperti misalnya
berjalan kaki
(30 men/hari 4-5 hari
seminggu)

4-9 mm Hg

Kurangi konsumsi alkohol

Batasi konsumsi
2-4 mm Hg
alkohol,jangan lebih dari
Seventh Report of the Joint National Committee on Prevention, Det
2 /hariSource:
utk The
pria
1 of High Blood Pressure JNCVII. JAMA. 2003;289:2560
Evaluation,
and dan
Treatment

Main classes of antihypertensive drugs

Diuretics
Inhibit the reabsorption of salts and water from kidney
tubules into
the bloodstream

Calcium-channel antagonists
Inhibit influx of calcium into cardiac and smooth muscle

Beta-blockers
Inhibit stimulation of beta-adrenergic receptors

Angiotensin-converting enzyme (ACE) inhibitors

Inhibit formation of angiotensin II

Angiotensin II receptor blockers (ARBs)

Inhibit binding of angiotensin II to type 1 angiotensin II
Receptors

Vasodilators/Centrally acting
Direct renin inhibitors

Special consideration in Antihypertensive Potential side effects

Thiazide diuretics should be used cautiously in gout or a history of
significant hyponatremia.
BBs should be generally avoided in patients with asthma, reactive
airways disease, or second- or third-degree heart block.
ACEIs should not be used in individuals with a history of angioedema.
Aldosterone antagonists and potassium-sparing diuretics can cause
hyperkalemia.

Drug Treatment
Uncomplicated Hypertension
The 2009 updated European Society of Hypertension
guidelines recommend initiating therapy in the elderly
with thiazide diuretics, CAs, ACEIs, ARBs, or beta
blockers based on a meta-analysis of major
hypertension trials
Complicated Hypertension
Beta blocker; CAD with hypertension and stable
angina or prior MI
A long-acting dihydropyridine CA : in addition to the
beta blocker when the BP remains elevated or if angina
persists.
An ACEI should also be given, particularly if LV
ejection fraction is reduced and/or if HF is present.

Drug Treatment
Angina; verapamil SRtrandolapril strategy.
Acute coronary syndromes, beta blockers and ACEI,
with additional drugs added as needed for BP control.
Verapamil and diltiazem should not be used with
significant LV systolic dysfunction or conduction
system
Beta blockers with intrinsic sympathomimetic
activity must not be used after MI.

Drug Treatment
Considerations for Drug Therapy,
Great caution on alterations in drug distribution
and disposal and changes in homeostatic CV
control, as well as QoL factors
Initiation of Drug Therapy
Start at the lowest dose and gradually
Target 140 mm Hg, if tolerated, (< 80 year )

 Rapid initial reduction of BP

within the first 3 months of
therapy is required to improve
cardiovascular outcomes

Do not go too low

ACCORD BP (Action to Control
Cardiovascular Risk in Diabetes Blood
Pressure) trial found no additional benefit;
target SBP 120 mm Hg versus a target of
140 mm Hg.
INVEST (International VErapamil
SR/Trandolapril Study) extended follow-up,
diabetes cohort, suggest an increase in
mortality when on-treatment SBP is 115
mm Hg or DBP 65 mm Hg.

 Some guidelines recommend reducing BP

to 130/80 mm Hg in CAD patients, there is
limited evidence to support this lower
target in elderly patients with CAD.
Observational data show the nadir BP for
risk (CAD) was: 135/75 mm Hg for 70 to 80
years of age 140/70 mm Hg for 80 years of
age.

Benefits of Treating Hypertension

Younger than 60 (reducing BP 10/5-6 mmHg)
reduces the risk of stroke by 42%
reduces the risk of coronary event by 14%

Older than 60 (reducing BP 15/6 mmHg)

reduces overall mortality by 15%

reduces cardiovascular mortality by 36%
reduces incidence of stroke by 35%
reduces coronary artery disease by 18%

Older than 60 with isolated systolic hypertension (SBP

160 mm Hg and DBP <90 mm Hg)
42% reduction in the risk of stroke
26% reduction in the risk of coronary events

Lancet 1990;335:827-38
Arch Fam Med 1995;4:943-50

Hypertension in the Very

Elderly Trial (HYVET)
The first prospective trial in patients
with hypertension >80 years of age
Goal <150 mmHg prevent fatal and
nonfatal events (incidence of nonfatal
cardiovascular eventsin particular of
strokebut not cardiovascular death)
Diuretic (indapamide) + ACE-inhibitor
(perindopril)

Routine Laboratory Tests

Preliminary Investigations of patients with hypertension
1.
2.
3.
4.

Urinalysis
Blood chemistry (potassium, sodium and creatinine)
Fasting glucose
Fasting total cholesterol and high density lipoprotein cholesterol
(HDL), low density lipoprotein cholesterol (LDL), triglycerides
5. Standard 12-leads ECG

Currently there is insufficient evidence to recommend routine

testing of microalbuminuria in people with hypertension who
do not have diabetes

Abnormal Urinary Albumin levels

Setting

Urinary albumin / creatinine level (mg/mmol)

Men

Women

Chronic kidney
Disease
Diabetes

>30
>2

>2.8

90% of Hypertensive Canadians

have other Cardiovascular Risk factors

10%
Reduction
in BP

10%
Reductio
n
in TotalC

45%
Reductio
n
in CVD

Emberson et al. Eur Heart J. 2004;25:484491