Management of hypertension in specific populations: a review

Abstract

Hypertension is a widespread global health issue that disproportionately affects certain populations, including self-identified Blacks, the older persons, patients with chronic kidney disease (CKD), and kidney transplant recipients. Hypertension disproportionately affects self-identified Black individuals, with a prevalence of 57.1% compared to 43.6% in non-Hispanic White individuals. This disparity is linked to social determinants of health. Furthermore, APOL1 genetic variants found in self-identified Black individuals increase their susceptibility to kidney injury and CKD, which can subsequently contribute to hypertension. Although in the past thiazide diuretics and calcium channel blockers (CCBs) were suggested to be more effective in Black adults, combination therapy is now generally required, with comparable efficacy across populations. In the older persons, hypertension affects approximately 70% of individuals over the age of 65 years, often manifesting as isolated systolic hypertension (ISH). Trials like the SPRINT study (Systolic Blood Pressure Intervention Trial) have demonstrated the benefits of lowering systolic blood pressure (SBP) to less than 120 mmHg; however, treatment must take into account factors like orthostatic hypotension and frailty. Patients with CKD have a hypertension prevalence of 80-85%. The KDIGO (Kidney Disease: Improving Global Outcomes) 2021 guidelines recommend maintaining an SBP of less than 120 mmHg based on the SPRINT trial, although this goal may increase the risk of acute kidney injury (AKI). Renin-angiotensin-aldosterone system (RAAS) blockers are typically preferred for those with proteinuric CKD. Kidney transplant recipients also experience high rates of hypertension, with approximately 85% affected. The KDIGO 2021 guidelines suggest a blood pressure (BP) target of less than 130/80 mmHg in kidney transplant patients, with a focus on promoting graft survival. Dihydropyridine CCBs and angiotensin receptor blockers are commonly preferred treatments in kidney transplant patients, especially for patients with proteinuric kidney disease. This review synthesizes current evidence regarding the unique challenges and management strategies for hypertension in these specific groups. It examines the prevalence, underlying mechanisms, and treatment considerations while emphasizing the importance of individualized care to achieve optimal BP control and reduce cardiovascular risk.