Tuesday, December 24, 2013

JNC 8: A Nephrology fellow's perspective

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) was released in 2003 and since that time has been an often referenced tool for clinicians seeking to treat hypertension.  From that report we were given useful information such as classification of hypertension along a spectrum of blood pressure ranges , from pre-hypertension to stage 1 and ultimately to stage  2 hypertension.  A goal of <140/90 mmHg should be our target for most of the population, and less than 130/80mmHG for those special populations with increased cardiovascular risk, such as those with diabetes or chronic kidney disease.  Thiazide diuretics were the preferred initial drug for those with uncomplicated stage 1 hypertension.  Multidrug therapy was useful for stage 2 or failure to reach the goal blood pressure.  Simple, straightforward, yet leaving a lot of questions unanswered. Many of us in the nephrology field were awaiting the JNC 8 for years.
So as you can imagine when the JNC 8 came along, just released on December 18, I was anticipating a lot of questions being resolved.  As a nephrology fellow I was looking forward to more specific guidelines and recommendations: what should I do with my elderly hypertensives, my patients with proteinuric CKD?  How about my hemodialysis patients?  Finally, I would get some insightful, specific recommendations on these special populations, or so I thought.
What I did get was a list of 9 recommendations, 9 generic recommendations that do not address my concerns as a budding nephrologist.  In patients over 60 years of age, target a BP of <150/90 mmHg.  However, if they are able to achieve a systolic BP <140 mmHg without adverse effects, than that is fine too.  A goal of <140/90mmHg should be targeted in patients under 60.  If one is over 18 years old and has CKD or diabetes, once again target <140/90mmHg.  An angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) should be used here.   In the black population, those with or without diabetes, a thiazide type diuretic or calcium channel blocker is the preferred initial agent of choice.  In the non black population, a thiazide type diuretic, calcium channel blocker, ACEI, or ARB, can be used. 
While nephrology specific questions were not addressed in detail, these guidelines do serve as the blueprint to help treat those with essential hypertension.  They are a framework for all clinicians to follow to help with all patient types.   They should be succinct, straightforward treatment recommendations that can be quickly applied in the clinic.
 That is exactly what these new guidelines are.  This is very useful information that will benefit many patients.  Tolerating higher blood pressures in elderly patients and avoiding some of the adverse effects of the medications is surely a good thing.  This will help a lot of clinicians realize that attaining a goal blood pressure is oftentimes more important than how it is achieved.  Ultimately, patients and physicians will see positive results.    

The AAFP gives a summary of the guidelines. Also check out the review on BMJ blog on JNC 8

Louis Spiegel, MD
Renal Fellow in training

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