Min Jun|Brenda R. Hemmelgarn
Strategies for BP Control in Developing Countries and Effects on Kidney Function
Institute for Community Health|University of Calgary
ckd major public health threat worldwide prevalence ckd among adults estimated 1015 globally 13 evidence showing continually increasing trend made worse rising rates diabetes hypertension primary causes ckd well commonly observed comorbid conditions highrisk group trend particularly concerning developing countries heightened resource constraints underdeveloped health care infrastructure limit access appropriate care well established management patients kidney disease particularly related esrd associated enormous financial cost example united states approximately 26 million people suffer ckd 4 660000 people requiring form rrt 5 incurring cost 309 billion medicare 2013 6 exorbitant costs associated esrd therapy make certain lifesaving treatments dialysis simply unaffordable many developing countries highlighting particular importance preventive measures settings strategies aimed controlling established modifiable renal cardiovascular risk factors among patients ckd control bp considered single effective intervention 7 high bp observed majority patients ckd loglinear relationship 89 elevated bp increased risk esrd reported accordingly observational trial data 1014 sufficiently established reducing bp delays renal progression ckd esrd bp control thus cornerstone management prevent onset delay progression ckd current clinical guidelines 15 widely advocate bp reduction strategies including pharmacologic lifestyle interventions given increasing prevalence ckd developing countries excessive costs associated ckd management strong need efficient costeffective prevention strategies aimed adequate bp control delay prevent ckd progression countries developing health care systems issue clinical journal american society nephrology jafar et al 16 assessed effectiveness interventions involving 1 homebased communication strategy highlighting importance lifestyle changes adherence antihypertensive medication referred home health education hhe andor 2 general practitioner gp education involving singleday training session discussing standard bp management strategies basis clinical guidelines 1718 kidney function longterm renal survival outcomes among patients hypertension basis extended followup study previously completed control blood pressure risk attenuation cobra trial cobra trial 22 cluster randomized controlled trial randomized 12 low middleincome communities karachi pakistan hhe gp training interventions usual care assess effects bp levels among adults age 40 years old hypertension 19 posttrial observational study included 7 years followup 2 years trial 5 years posttrial egfr measurements recorded baseline 7year followup visit primary outcome assessed change egfr baseline 7year posttrial followup visit across original four treatment groups whereas secondary outcomes included 20 decline egfr baseline 7year followup death caused kidney failure composite outcomes involving combination individual secondary outcomes original 1341 participants cobra trial 1271 948 included observational study relatively similar numbers patients across four treatment groups original trial majority patients relatively well preserved kidney function 89 egfr60 mlmin per 173 m2 baseline adjustment certain differences baseline characteristics across treatment groups literacy comorbid conditions including history stroke heart disease mean egfr among patients randomized interventions remained unchanged 88 versus 893 mlmin per 173 m2 baseline 7year followup respectively whereas significant decline egfr 36 mlmin per 173 m2 875 versus 849 mlmin per 173 m2 observed among patients usual care group compared usual care combined hhe gp training group associated lower risk experiencing 20 decline baseline egfr adjusted risk ratio 053 95 confidence interval 029 096 well lower risk composite outcome death kidney failure 20 decline baseline egfr adjusted risk ratio 047 95 confidence interval 025 089 combined hhe gp training group associated lower risk composite outcome allcause death 20 decline baseline egfr comparable associations benefit similar interventions related education behavioral change reported among patients early ckd developing countries 2021 pilot cluster randomized controlled trial 20 conducted mexico involving two primary health care units providing care patients type 2 diabetes early ckd mean egfr 812857 mlmin per 173 m2 assessed effects 6month gp educationbased intervention including training sessions role bp ckd progression clinical guideline recommendations management ckd among others study showed gps received educationbased intervention attained improved clinical competence compared control group achieved significantly better bp control preservation kidney function patients similar levels benefit reported studies assessed educationbased hypertension management strategies broader patient groups developing countries 2223 many high risk developing ckd example cobra trial 19 study study jafar et al 16 derives cohort reduction bp almost 11 mmhg end trial group received hhe gp training intervention reported importantly subsequent costeffectiveness analyses showed combined intervention hhe gp training significantly cost effective usual care individual components combined strategy 24 results reported jafar et al 16 warrant implementation interventions public health programs health systems developing countries results along early reports promising suggest among patients high risk developing ckd earlystage ckd low middleincome countries behavioral changebased interventions associated significant improvements shortterm outcomes including bp quality care indicators associated longterm outcomes antihypertensive medication adherence however although results encouraging health services interventions objective assessing effect ckd management strategies developing countries scarce overall studies date relatively small assess longterm clinical outcomes esrd death also limitations study jafar et al 16 noted 14 n182 study cohort ckd defined egfr60 mlmin per 173 m2 therefore whether strategies would associated similar evidence renal benefit among patients progressed ckd unknown although baseline egfr available 1271 patients 7year followup egfr missing 50 n641 study cohort values imputed basis statistical models also note change egfr basis two measurements 7 years apart addition proportion patients missing egfr 7year visit varied ranging 39 60 across four treatment groups increasing potential attrition bias despite limitations given adequate bp control among highrisk patient groups ckd low 132 25 awareness ckd significantly lower developing countries compared developed countries 26 follows simple interventions basis education communication importance established prevention strategies including bp management may significant effect population level therefore warrants consideration including assessment costeffectiveness sustainability prevention strategies specific ckd management developing countries disclosures none