Hypertension and Chronic Kidney Disease Including Dialysis

Kidney disease is most commonly due to diabetes and poorly controlled hypertension. These account for over 60% of people on dialysis. The data are very clear that: if blood pressure goals of less than 130/80 mm Hg, glucose control of HbA1c less than 7%, and cholesterol are managed, kidney disease progression is slowed. Moreover, agents to maximally slow kidney disease progression that must be used as pillars of therapy include (1) blockers of the renin angiotensin system in maximally tolerated doses (2) a sodium-glucose cotransporter-2 (SGLT2) inhibitor, and finally finerenone, a nonsteroidal mineralocorticoid receptor antagonist in those with diabetes. As kidney function declines below an estimated glomerular filtration rate (eGFR) of 45 mL/min/1.73 m2, the risk of hyperkalemia is present and may preclude kidney-saving therapy. Newer potassium binders that are well tolerated and can be used daily are demonstrated to aid in taking such therapy and should be used. These and related issues are discussed in the chapter.