Strategies for BP Control in Developing Countries and Effects on Kidney Function

Abstract

CKD is a major public health threat worldwide. The prevalence of CKD among adults has been estimated to be 10%-15% globally (1-3), with evidence showing a continually increasing trend made worse by the rising rates of diabetes and hypertension, the primary causes of CKD as well as the most commonly observed comorbid conditions in this high-risk group. This trend is particularly concerning in developing countries, where heightened resource constraints and underdeveloped health care infrastructure limit access to appropriate care. It is well established that management of patients with kidney disease, particularly those related to ESRD, is associated with enormous financial cost. For example, in the United States, approximately 26 million people suffer from CKD (4), with .660,000 people requiring some form of RRT (5), incurring a cost of $30.9 billion to Medicare in 2013 (6). The exorbitant costs associated with ESRD therapy make certain lifesaving treatments, such as dialysis, simply unaffordable in many developing countries, highlighting the particular importance of preventive measures in these settings.Of the strategies aimed at controlling established modifiable renal and cardiovascular risk factors among patients with CKD, control of BP has been considered the "single most effective intervention" (7). High BP is observed in the majority of patients with CKD, in whom a log-linear relationship (8,9) between elevated BP and an increased risk of ESRD has been reported. Accordingly, observational and trial data (10-14) have sufficiently established that reducing BP delays renal progression of CKD to ESRD. BP control is, thus, a cornerstone of management to both prevent the onset and delay the progression of CKD, and current clinical guidelines (15) widely advocate BP reduction strategies, including both pharmacologic and lifestyle interventions. Given the increasing prevalence of CKD in developing countries and the excessive costs associated with CKD management, there is a strong need for efficient, cost-effective prevention strategies aimed at adequate BP control to delay or prevent CKD progression in countries with developing health care systems.In this issue of the Clinical Journal of the American Society of Nephrology, Jafar et al. (16) assessed the effectiveness of interventions involving (1) a home-based communication strategy highlighting the importance of lifestyle changes and adherence to antihypertensive medication (referred to as home health education [HHE]) and/or (2) general practitioner (GP) education involving a single-day training session discussing standard BP management strategies on the basis of clinical guidelines (17,18) on kidney function and long-term renal and survival outcomes among patients with hypertension on the basis of an extended follow-up study of the previously completed Control of Blood Pressure and Risk Attenuation (COBRA) Trial. The COBRA Trial was a 232 cluster, randomized, controlled trial, which randomized 12 low-to middleincome communities in Karachi, Pakistan to HHE, GP tr...

Preventing CKD in Developed Countries

“…[71][72][73][74] Interventions to manage hypertension and promote weight loss indeed have been associated with reduced risk of CKD as well as improved outcomes in those with CKD. 67,[75][76][77][78][79][80][81]…”

Global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy

“…[21][22][23][24][25][26][27][28] Good management of diabetes, hypertension, and excess weight reduces the risk of CKD and improves outcomes among those with CKD. [29][30][31][32][33][34][35] Nephrotoxin exposure is a common and under-recognized risk factor for AKI and CKD. [36][37][38][39][40][41][42] Nephrotoxic agents, e.g., non-steroidal anti-inflammatory drugs (NSAIDs), iodinated contrast media, and certain alternative remedies among many others, are widely available and frequently used in patients at risk of CKD.…”

Reducing major risk factors for chronic kidney disease

“…[29][30][31][32][33][34][35][36] Conversely, interventions to manage hypertension and promote weight loss are associated with reduced risks of developing CKD and better outcomes among those living with CKD. 2,[37][38][39][40][41][42][43] Gaps. Epidemiological assessment, followed by prioritization of CKD risk factors according to their contribution to the local burden of the disease, is important to determine where public health care efforts should be focused on reducing the population burden of CKD.…”