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Lancet. 2015 Oct 17;386(10003):1588-98. doi: 10.1016/S0140-6736(15)00418-3.

The double challenge of resistant hypertension and chronic kidney disease.

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INSERM Centre d'Investigations Cliniques (CIC)-1433, and INSERM U1116, Nancy, France; Institut Lorrain du Cœur et des Vaisseaux, CHU Nancy, Vandoeuvre lès Nancy, France; Université de Lorraine, Nancy, France; Association Lorraine pour le Traitement de l'Insuffisance Rénale, Vandoeuvre lès Nancy, France. Electronic address:
Division of Nephrology, Ambroise Paré University Hospital (APHP), University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), Boulogne-Billancourt, Paris, France; INSERM U1018, Research Centre in Epidemiology and Population Health (CESP), UVSQ, Villejuif, France.
APHP, Hôpital Européen Georges Pompidou, Unité d'Hypertension artérielle, Paris, France; Université Paris Descartes, Paris, France; INSERM CIC-1418, Paris, France.
Department of Medicine, University of Chicago Medicine, Chicago, IL, USA.
Department Internal Medicine, Ruperto Carola University of Heidelberg, Germany.
Parhon University Hospital, Grigore T Popa University of Medicine, Iasi, Romania.
Renal and Transplantation Department, Guy's and St Thomas' Hospitals, London, UK.
Internal Medicine IV-Nephrology and Hypertension, Saarland University Medical Centre, Homburg, Germany.
ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey.
Nephrology, Hypertension and Renal Transplantation Unit, Ospedali Riuniti, Reggio Calabria, Italy; CNR (National Research Council of Italy) Institute of Clinical Physiology (IFC), Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Ospedali Riuniti, Reggio Calabria, Italy.
Division of Nephrology, IIS-Fundacion Jimenez Diaz, Madrid, Spain; School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain; Red de Investigacion Renal (REDINREN), Madrid, Spain; Insituto Reina Sofia de Investigaciones Nefrológicas (IRSIN), Madrid, Spain.
Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Belgium.
Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland.
CNR (National Research Council of Italy) Institute of Clinical Physiology (IFC), Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Ospedali Riuniti, Reggio Calabria, Italy.
INSERM U970, Hôpital Européen Georges Pompidou, Paris.
UVSQ, UMRS 1018, Paris-South University, Villejuif, France.
Department of Nephrology, Nutrition, and Dialysis, Centre Hospitalier Lyon Sud, Carmen-CENS, Université de Lyon, Lyon, France.


Resistant hypertension is defined as blood pressure above goal despite adherence to a combination of at least three optimally dosed antihypertensive medications, one of which is a diuretic. Chronic kidney disease is the most frequent of several patient factors or comorbidities associated with resistant hypertension. The prevalence of resistant hypertension is increased in patients with chronic kidney disease, while chronic kidney disease is associated with an impaired prognosis in patients with resistant hypertension. Recommended low-salt diet and triple antihypertensive drug regimens that include a diuretic, should be complemented by the sequential addition of other antihypertensive drugs. New therapeutic innovations for resistant hypertension, such as renal denervation and carotid barostimulation, are under investigation especially in patients with advanced chronic kidney disease. We discuss resistant hypertension in chronic kidney disease stages 3-5 (ie, patients with an estimated glomerular filtration rate below 60 mL/min per 1·73 m(2) and not on dialysis), in terms of worldwide epidemiology, outcomes, causes and pathophysiology, evidence-based treatment, and a call for action.

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