Abstract
Hypertension is the leading causative factor of both cardiovascular diseases and renal failure. There is a strong association of CKD to CVD independently. Additionally, hypertension can either cause or result from cardiovascular diseases. Management of hypertension is essential for people living with Chronic Kidney disease and or CVD. Controlled blood pressure lowers the risk of renal failure, cardiovascular diseases, and prevents the progression of the disease. Understanding the evidence of the relationship between the conditions, and it is vital to understand the existing guidelines and address knowledge gaps. A systematic review of existing evidence-based data and procedures have been reviewed to form the basis of the discussion. Proper management strategies of hypertension will have a significant effect on CKD and CVD. Optimal approaches have been made in the control and prevention of HTN to address or prevent the other comorbidities. However, a lot of societal, research, and clinical questions are yet to be addressed. More high-quality clinical trials should be done documented well to address the existing gaps. Generally, Proper management of hypertension through nonpharmacologic and pharmacologic therapies is crucial. It helps in the reduction of cardiovascular and CKD mortalities.
Keywords: High Blood Pressure (HBP), Systolic Blood Pressure (SBP) , Diastolic Blood Pressure (DBP) , Chronic Kidney Disease (CKD), estimated Glomerular Filtration Rate (eGFR).
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Introduction
Hypertension is a chronic condition resulting from a long-term high force of blood against the artery, also known as high blood pressure. The blood pressure shows the amount of blood pumped by the heart and the resistance the blood vessels offer for the blood to flow. The condition is a silent killer in most cases, diagnosed accidentally. An individual can live with hypertension for a very time without any clinical symptoms yet develop long-term complications (Carey, Muntner, Bosworth, & Whelton, 2018) . Management of high blood pressure is vital because uncontrolled blood pressure increases the risk of severe health problems such as cardiovascular diseases and renal failure.
High blood pressure is the primary factor causing cardiovascular diseases and kidney disease. The commonly attributing factor for cerebrovascular and cardiovascular diseases is suboptimal control of blood pressure. 58% of hemorrhagic and ischemic cases, 55% cases of ischemic heart disease, 50% stroke cases, and 58% of other types of CVD result from poorly managed high blood pressure, according to ( Forouzanfar et al., 2017). Additionally, it is the leading cause of dementia, kidney disease progression, end-stage kidney disease, and chronic kidney disease. Epidemiological studies done on large-scale have provided convincing evidence that the relationship between risk of nonfatal and fatal ischemic illness, stroke, noncardiac vascular disease, heart failure, and high blood pressure is a graded association. The fact is not influenced by other factors such as age, gender, or ethnicity. The optimal blood pressure is 115/75 mm Hg, and a 20 mm Hg increment of the SBP or 10 mm Hg of DBP doubles the risk of a cardiovascular event that is fatal (GBD 2016 Risk Factors Collaborators, 2016).
HBP can either cause CKD or result from the condition. Additionally, independently both conditions are contributing factors to the development of cardiovascular diseases. The three chronic illnesses are interrelated, and if one is not well managed, it will lead to the other. When two or three of them exist together, the risk of mortality is increased substantially. The severity of hypertension is associated with a decline in eGFR. Individuals with either stage three or stage four of CKD have an increased risk of dying from Cardio Vascular diseases than disease progression to ESRD (end-stage renal disease). However, proper management of hypertension to maintain blood pressure at normal levels slows the decline of eGFR, passage of the disease to ESRD, and development of cardiovascular diseases.
Several mechanisms lead to the development of HBP for individuals with existing CKD. When the sympathetic tone increases due to afferent signals generated by kidneys declining in functionality, hypertension develops. The decline of eGFR promotes the retention of water and salt in the body because of the RAAS (renin-angiotensin-aldosterone system). It increases salt sensitivity due to endothelial dysfunction, increasing the stiffness of the arteries. It is a common phenomenon throughout CKD, and it is the causative factor for hypertension (Judd & Calhoun, 2015) . Upon the development of hypertension, other factors such as the rise of oxidative metabolism and renal hypoxia contribute to the progression of CKD and HBP. There is a complicated relationship between the three conditions. The interrelationship between hypertension and CKD increases the risk of the coexistence of the three diseases. Therefore, this research is purposed to address the current issues among the patients and the management of the conditions. Proper management strategies of hypertension will have a significant effect on CKD and CVD.
Critical Appraisal of Evidence
The appropriate to reduce the risk of developing cardiovascular diseases and chronic kidney disease is the management of hypertension. Management of hypertension includes adherence to therapy, lifestyle modification, and appropriate drug choice. The control of hypertension is effective only when the BP measurements are accurate. It will help an individual and their caregivers to take the most appropriate course of action. Often, the management of hypertension is purely based on office or clinical BP readings, which are not accurate. Inaccuracy results from failure to take repeated measurements, white-coat hypertension, and diurnal variation (Maraj et al., 2013) . Upon having a precise reading, hypertension can be managed using the following approaches.
Lifestyle modification is vital in the management and prevention of hypertension. An update on secondary prevention trials of blood pressure reduction and cardiovascular prevention shows that this intervention helps alter CKD and CVD risk. Different studies have used similar approaches to provide convincing evidence of the effectiveness of lifestyle modification in disease management. Two common strategies that have been used are the high-risk approach and population approach. The high-risk techniques address people susceptible to hypertension due to other contributing factors that are non-modifiable such as positive family history. While the population approach targets people that are living with the condition to help prevent disease progression ( Drozdz, & Kawecka-Jaszcz, 2014) . High-risk strategies are more effective compared to the population approach. The conclusion has been drawn from a study that targeted a smaller population hence could be biased. Research on a broader community will provide more convincing evidence.
The most effective approach to reducing the global burden of CVD and CKD is population strategies should be supplemented with high-risk strategy. The main focus should be on modifiable factors such as diet and the use of tobacco to manage and prevent hypertension. Research studies done by Framingham reveal that 31% of stroke cases occur among patients with high normal or normal hypertension. Additional studies have been to find out more about the relationship between stroke and hypertension. VALUE study shows that amlodipine is more beneficial than valsartan because of the rapid control and reduction of hypertension. Therefore, the most important thing is to manage the condition as soon as it is made to know. Research done on secondary prevention trials by (Staessen JA, Li Y, Thijs L, Wang J-G), hypertension life course analysis by (Franco OH, Peeters A, Bonneux L, de Laet C) and The Didima Study by (Stergiou GS, Thomopoulou GC, Skeva II, Mountokalakis TD) have similar findings.
Several clinical trials show that lowering blood pressure lowers the risk of developing myocardial infraction CVDs by 20% - 25%. The risk of stroke development is reduced by 35% - 40%, while heart failure is reduced by 50% ( Drozdz, & Kawecka-Jaszcz, 2014) . However, the medical team says that they could be a further reduction of the risks. Another study done is the (MDRD) Modification of Diet in Renal Disease to investigate the relationship between standard artery pressure and rate of eGFR (Judd & Calhoun, 2015) . Results obtained revealed no effect for the patients with proteinuria. The results mirror those done to an African American population of nondiabetic people. The gap in the study was the failure to consider the potential benefits of blood pressure control on cardiovascular endpoints.
Implications for Future Research
Comprehensive research has been done on hypertension, cardiovascular diseases, and chronic kidney disease separately. Data presented from the research has aided and still helps in addressing chronic conditions. The conditions have been studied independently to understand the background and together to show their relationship. The critical research studies using in compiling the report are Research studies done by Framingham, VALUE studies, and research done on secondary prevention trials.
There exist similarities between these studies. All the studies show that proper management of hypertension prevents the occurrence of disease progression of CVD and or CKD. Different cohorts of patients have been put on trial studies and responded positively to proper management. Management of hypertension is very critical, and the researchers have recommended vital actions that can be used to address the issue. The strategies that come out as clear recommendations across all the studies are lifestyle modification, diet therapy, and medication. Also, using a combination of population and high risk-strategies is more effective.
Evidence-based practice and expert opinion on the management of the conditions has been criticized often for lack of flexibility. Some consider them not to be helpful because of clinical decision-making, which has its complexities. Also, CKD management guidelines reviewed are few when compared to the other conditions of equal magnitude. It shows a scarcity of high-quality clinical trials for chronic kidney disease. Future researchers for optimal treatment should address the existing knowledge gap. Clear guidelines outlining optimal care and treatment for hypertensive patients with CKD is crucial because the patients are managed in primary care jointly.
There is a contrast in the optimal blood pressure recommended for patients with CKD and CVD. ACC guidelines established in 2017 recommend BP of less than 130/80 mm Hg. The UK Renal Association and National Health and Care Excellence (NICE) give a target of 140/90 mm Hg. KDIGO guidelines recommend lower blood pressure while the 2018 ESC/ESH recommends systolic blood pressure of less than 140 mm Hg. The optimal blood pressure is 115/75 mm Hg, and a 20 mm Hg increment of the SBP or 10 mm Hg of DBP doubles the risk of a cardiovascular event that is fatal, according to GBD 2016 (Judd & Calhoun, 2015) . The figures given are different though critical because they can either increase or decrease disease progression and mortality. Evidence used to arrive at the various guidelines should be used to understand the differences.
Summary and Conclusion
Much progress is evident in efforts made to understand HBP as a risk factor of cardiovascular diseases and chronic kidney disease. Optimal approaches have been made in the control and prevention of HTN to address or prevent the other comorbidities. However, a lot of societal, research, and clinical questions are yet to be addressed. They require comprehensive results and convincing evidence to de documented. Some forms of CKS present HTN as the earliest clinical sign of kidney problems such as polycystic disease. Proper management of hypertension reduces the risk of both kidney outcomes and cardiovascular diseases. Many clinical studies have been done to determine the most effective ways of managing hypertension that will have a direct impact on CVD and CKD. Trials such as salt-sensitive high blood pressure in animal models of kidney injury, BP impaired dipping during sleep, and BP responses upon restriction of dietary salt have been done to find effective management strategies. Also, recommendations have been made on the use of angiotensin or ACEL receptor blocker, appropriate diuretic therapy, and restriction of dietary salt. Proper management of hypertension through nonpharmacologic and pharmacologic therapies is crucial. It helps in the reduction of cardiovascular and CKD mortalities. Additionally, there are recommendations on the use of antihypertensive medication during bedtime for all patients with CKD.
References
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Drozdz, D., & Kawecka-Jaszcz, K. (2014, September). Cardiovascular changes during chronic hypertensive states . Pediatric nephrology (Berlin, Germany). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4147208/.
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Judd, E., & Calhoun, D. A. (2015, March). Management of hypertension in CKD: beyond the guidelines . Advances in chronic kidney disease. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4445132/.
Maraj, I., Makaryus, J. N., Ashkar, A., McFarlane, S. I., & Makaryus, A. N. (2013). Hypertension management in the high cardiovascular risk population . International journal of hypertension. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580899/.
