{"doi":"10.2215/cjn.09720822","title":"Resistant Hypertension in Chronic Kidney Disease","abstract":"CKD has long been known to be a risk factor for hypertension. Hypertension occurs in 60%–90% of patients with CKD, with higher prevalence occurring in later stages of CKD (1). Elevated BP, in turn, can worsen CKD, creating a feedback loop in which both disorders may inexorably progress. The inter-relationship between CKD and hypertension reflects a complex interplay of physiologic factors, including endothelial dysfunction, dysregulation of the sympathetic nervous system, and excessive sodium retention leading to volume overload (1). The resulting feedback loop contributes to a distinctly elevated risk of difficult-to-control or resistant hypertension among patients with CKD. Resistant hypertension is defined as BP that remains uncontrolled despite the use of at least three antihypertensive agents with different mechanisms of action taken at the highest tolerated dose (which may or may not require the use of a diuretic depending on the guideline) or the need for four or more antihypertensive agents to achieve adequate BP control (2,3). Resistant hypertension occurs more commonly among patients with CKD than the general population. As guidelines recommend more stringent systolic BP goals among patients with CKD (e.g., the 2021 Kidney Disease Improving Global Outcomes [KDIGO] guidelines' target of <120 mm Hg [4]), the disproportionate prevalence of resistant hypertension in our patients will continue to increase. Resistant hypertension carries substantial risk, and there is a dose-response relationship of the number of antihypertensive agents required to achieve adequate BP control with adverse kidney and cardiovascular outcomes. In the Chronic Renal Insufficiency Cohort, participants with resistant hypertension had a 66% higher risk of heart failure and a 24% higher risk of mortality compared with those with BP controlled on fewer agents (5). In the same cohort, participants with refractory hypertension, defined as uncontrolled BP despite five antihypertensive agents, had a 73% greater risk of progression of kidney disease and up to a 2.7-fold higher risk of adverse cardiovascular events compared with those with resistant hypertension (6). Accordingly, identification and appropriate management of resistant hypertension in patients with CKD are of the utmost importance to mitigate undue adverse outcomes. In this issue of CJASN, An et al. (7) provide an expansive analysis of the prevalence of resistant hypertension and patterns of antihypertensive medication use among patients with CKD in two large US electronic health record–based cohorts: Kaiser Permanente of Southern California (KPSC; from 2014 to 2015) and the Veterans Health Administration (VHA; from 2018). More precisely, the authors evaluated the prevalence of apparent treatment-resistant hypertension—“apparent” due to frequent pseudoresistance, with the diagnosis of resistant hypertension limited by uncertain medication dosing and adherence as well as by suboptimal BP measurements inherent in any electronic health record–based study. Distinct from prior publications that evaluated the prevalence of resistant hypertension in CKD, which often used a BP threshold of <140/90 mm Hg to define resistant hypertension, the authors applied CKD-specific thresholds from recent guidelines (i.e., the 2017 American College of Cardiology [ACC]/American Heart Association [AHA] BP threshold of <130/80 mm Hg and the KDIGO systolic BP threshold of <120 mm Hg). Upon applying the ACC/AHA diagnostic BP threshold of <130/80 mm Hg, An et al. (7) observed that 39% of patients with CKD in KPSC had apparent treatment-resistant hypertension (28% were uncontrolled; i.e., they met criteria for apparent treatment-resistant hypertension with their BP above the threshold for hypertension) and that 35% of patients with CKD in VHA had apparent treatment-resistant hypertension (29% were uncontrolled) (7). Applying the KDIGO target systolic BP threshold of <120 mm Hg, 48% of patients with CKD in KPSC and 55% ","journal":"Clinical Journal of the American Society of Nephrology","year":2022,"id":283964,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":6,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9536,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2022-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":228812,"name":"Jordana B. Cohen","orcid":"0000-0003-4649-079X","position":1,"is_corresponding":false},{"id":961220,"name":"Rachel Shulman","orcid":"0000-0002-1230-2693","position":0,"is_corresponding":true}],"reference_count":12,"raw_metadata":null,"created_at":"2026-07-19T00:29:32.702533Z","pmid":"36400566","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}