Chronic kidney disease (CKD) and high blood pressure (BP) are closely
linked and, when not managed appropriately, can lead to serious
outcomes such as myocardial infarction, stroke, heart failure, and
progression to kidney failure. Among patients with CKD, uncontrolled
hypertension (HTN) is one of the most common modifiable risk factors
for cardiovascular events and CKD progression, regardless of the
cause of CKD. The prevalence of HTN is 67% to as high as 92% among
individuals with CKD; the majority of patients with CKD and HTN do
not achieve BP targets. In a recent World Health Organization report,
62% of deaths from CKD were attributed to elevated systolic BP.
Pathological excess of aldosterone induces HTN by forcing the kidneys
to excessively retain sodium and water, increasing blood volume,
and lowering potassium. Beyond fluid retention, it causes HTN
by increasing vascular resistance, stimulating inflammation, and
promoting vascular/cardiac fibrosis and remodeling. Excessive
aldosterone damages the kidneys; achieving optimal BP control
and mitigating the risk of aldosterone-related adverse events are
cornerstones in the management of patients with HTN and CKD.
Mineralocorticoid receptor antagonists (MRAs), which target the
renin-angiotensin-aldosterone system (RAAS), do not fully inhibit
the deleterious effects of aldosterone and may increase serum
aldosterone concentrations. Highly selective aldosterone synthase
inhibitors (ASIs) have emerged as potential alternatives to MRAs;
ASIs decrease aldosterone synthesis, providing another strategy
to inhibit aldosterone effects without affecting cortisol production.
In this symposium, the role of aldosterone dysregulation in the
pathophysiology of cardiovascular, endocrine, and renal diseases will
be explained. Evidence with currently available MRAs for the treatment
of uncontrolled and resistant hypertension will be interpreted. The
rationale for development of highly selective ASIs will be described, and
emerging data with ASIs for the treatment of hypertension discussed.
Upon completion of this activity, participants should be able to: