Telehealth and Management Support for Hypertension in CKD: Time to Raise the Bar

Hypertension is estimated to affect 31.1% of the global adult population, a measure that translates to over 1.4 billion people, signifying its contributions to adverse health consequences, including cardiovascular (CV) diseases (ischemic heart disease, heart failure, and strokes), CKD, disability, and death.1,2 In people with CKD, it is estimated that 90% are affected by hypertension (compared with 52.8% of people without CKD), a prognostic factor for progression to kidney failure, CV events, and increased mortality.3 Uncontrolled hypertension is systolic BP (SBP) . 140 mm Hg and/or diastolic BP . 90 mm Hg when an individual is not being treated with BP lowering medications, treated with insufficient number of medications, or failure to attain BP control with the use of $3 medications—i.e., resistance hypertension.2 Despite known adverse consequences of hypertension, a large population remains at risk or are unaware or not receiving adequate treatment.4 Data from over 4.2 million people screened for hypertension from 2017 to 2019 as part of the May Measurement Month program identified BP control among all hypertensives to range from 31% to 33.2% and were 53.7%–60% among those receiving medications.4 A bidirectional relationship between hypertension and CKD has been well-established with the risk of progressive elevation of BP often culminating in kidney failure.5 On the other hand, preexisting CKD can complicate management of hypertension, exacerbating the condition via multiple mechanisms, including salt and water retention, increased sympathetic axis drive, and renin-angiotensin-aldosterone-system activation. It is clinically imperative to attain good BP control in CKD as stipulated by multiple guideline recommendations.6,7 This is complicated by the fact that uncontrolled hypertension in CKD also results from low medication adherence due to numerous severely compromised kidney function, patient misconceptions, or misunderstanding about their care, polypharmacy, low affordability and a access to medications due to excessive cost, and low literacy levels.8 Strategies on achieving optimal BP control in CKD are desperately needed, including standalone interventions, that use self-management with patient-guided systems, self-monitoring with telemonitoring, or reminder systems that may improve adherence to treatment and clinical outcomes.7 Furthermore, interdisciplinary strategies for BP management including those involving nonphysician health care worker (pharmacist, nurses, etc.), telehealth strategies, and strategies that combine these systems are also needed as they have often led to improved patient outcomes.9,10 For example, a study of diabetes/CKD patients with uncontrolled hypertension randomized to telemonitoring and pharmacist intervention or usual care reported better BP control in intervention patients than patients in the usual care group (57.2% versus 30.0%; P 5 0.001) at 6 and 12 months.9 Similarly, at 6 months of postintervention follow-up, BP control was significantly higher in the intervention than usual care group (71.8% versus 57.1%; P 5 0.003). 9 A recent systematic review of studies using telemonitoring and management support for BP management in patients with CKD (but excluding people receiving renal replacement therapy) showed significant reductions of SBP (28.8 mm Hg; P 5 0.02) and diastolic BP (22.4 mm Hg; P , 0.001) as well as significant increase of eGFR (5.4 ml/min per 1.73 m2; P , 0.001). 10 In this issue of Kidney360, Dopp and colleagues11 evaluated the effects of a fully virtual management system with usual nephrology care on BP control among Veterans Administration patients with difficult to manage hypertension and CKD. Patients with uncontrolled hypertension and referred for management to a nephrologist and a clinical pharmacist received a home BP monitor and instructions on how to use it. BP was measured daily at home and communicated over the phone, mailed in BP paper logs, or uploaded digitally using the home telehealth service before each appointment. The BP was managed through telephone visits conducted by the pharmacist every 4–12 weeks. The pharmacist, within approved scope of practice and nephrologist guidance as needed, adjusted BP medications to