If BP is controlled with medication, is there any risk of CKD?

🔴 If BP is controlled with medication, is there any risk of CKD? Yes, there can still be a risk of CKD even if hypertension is well controlled with medication, but the risk is substantially lower than with uncontrolled hypertension. 🔷 Pathophysiology of HTN induced CKD Hypertension → Intraglomerular pressure ⬆️ → chronic vascular/glomerular injury → nephrosclerosis → ↓ nephron number → CKD If antihypertensive treatment keeps BP controlled: BP control → ↓ intraglomerular pressure + ↓ vascular/glomerular injury → slower renal damage → much lower CKD risk 🔷 WHO specifically recognizes uncontrolled hypertension as a major cause of chronic kidney disease and good BP control helps reduce the risk of developing CKD. 🔴 But why isn't the CKD risk zero? Because hypertension may be only one of several risk factors: 🔷 Risk factors of CKD 📌 Diabetes mellitus 📌 Family history/genetic kidney disease 📌 Older age 📌 Obesity 📌 Previous AKI 📌 Proteinuria/albuminuria 📌 Smoking 📌 Recurrent nephrotoxic drug exposure 📌 Renal artery disease/vascular disease 📌 Previous glomerulonephritis And importantly it may be that hypertension before diagnosis, may already have caused renal glomerular injury. Controlling BP prevents further damage but doesn't necessarily reverse established nephron loss. 🔴 Clinically, what should you monitor? For a patient with treated hypertension, don't rely on BP alone. 🔷 At least periodically check: 1. Serum creatinine → eGFR 2. Urine ACR → albuminuria 🔷 CKD can exist even when serum creatinine looks "normal", particularly when albuminuria is present. Persistent eGFR <60 mL/min/1.73 m² or persistent albuminuria can establish CKD depending on the clinical context. So the conclusion is that, 🔷 Controlled BP ≠ no CKD risk. Rather, BP control markedly reduces the risk of hypertensive kidney damage and slows CKD progression, but it does not eliminate CKD risk from hypertension. If CKD/albuminuria is already present, ACE inhibitor or ARB therapy is particularly important in appropriate patients because of its antiproteinuric and renoprotective effects. 🔴 Thats why, guideline suggests ARB/ACEi as first line antihypertensive for HTN management in younger age (onset of HTN <55 Y of age) 🔷 KDIGO recommends RAS blockade for CKD with significant albuminuria, with monitoring of creatinine and potassium after initiation/dose escalation. As ACEi/ARB can cause Hyperkalemia or raised serum creatinine transiently. 🔴 SBA A 52-year-old man has hypertension controlled at 125–130/75–80 mmHg on medication. His serum creatinine is 0.9 mg/dL. Which is the best test to screen for early hypertensive kidney involvement? A. Serum urea B. Serum uric acid C. Urine albumin-to-creatinine ratio D. Renal ultrasound E. 24-hour urine volume Answer: C. Urine albumin-to-creatinine ratio (ACR) 🔴 Why? Albuminuria can detect renal damage before a significant fall in eGFR occurs. References: WHO Hypertension Guideline; WHO Kidney Disease guidance; KDIGO 2024 Clinical Practice Guideline for CKD; Davidson's Principles & Practice of Medicine; Harrison's Principles of Internal Medicine. Dr. Muhammad Mosleh Uddin MBBS (CMC), FCPS trainee (Cardiology) Chittagong medical college & hospital