Apparent treatment-resistant hypertension is present in a “substantial proportion” of patients with chronic kidney disease (CKD), investigators concluded in a paper examining its prevalence published in the Clinical Journal of the American Society of Nephrology.

These patients “would qualify for treatment intensification on the basis of contemporary guidelines,” Jaejin An, MD, of Kaiser Permanente Southern California in Pasadena, and colleagues wrote. “This would result in treatment regimens of four or more antihypertensive medications for many patients.”

Dr An’s team studied adult patients with CKD and treated hypertension from 2 large integrated health systems: 44,543 from Kaiser Permanente Southern California and 241,465 from the Veterans Health Administration (VHA). The prevalence rates of apparent treatment-resistant hypertension in CKD were 39% in the Kaiser Permanente cohort and 35% in the VHA cohort based on the 2017 ACC/AHA guideline and 48% and 55% based on the 2021 KDIGO guideline, Dr An and colleagues reported.

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The investigators defined apparent treatment-resistant hypertension as blood pressure above goal while prescribed 3 or more classes of antihypertensive medications or prescribed 4 or more classes of antihypertensive medications regardless of blood pressure.

Among the patients with CKD and apparent treatment-resistant hypertension, most had uncontrolled resistant hypertension or refractory hypertension, the authors wrote. “These data suggest an opportunity to improve treatment and outcomes in a population vulnerable to the adverse effects of high [blood pressure].”

With respect to study limitations, the investigators acknowledged that their study used office blood pressure measurements extracted from electronic health records and lacked data on out-of-office blood pressure measurements, which may be a more accurate assessment of patients’ blood pressure. “Because of differences between office [blood pressure] compared with ambulatory and home [blood pressure] measurements, the prevalence of apparent treatment-resistant hypertension may be overestimated.”

The authors said their study is one of the largest and most diverse to date examining apparent treatment-resistant hypertension among patients with CKD.


An J, Tamura MK, Odden MC, et al. Prevalence of apparent treatment-resistant hypertension in chronic kidney disease in two large US health care systems. Clin J Am Soc Nephrol. Published online September 9, 2022. doi:10.2215/CJN.04110422