Telehealth and Management Support for Hypertension in CKD: Time to Raise the Bar

Hypertension is estimated to affect 31.1% of the global adult population, a measure that translates to over 1.4 billion people, signifying its contributions to adverse health consequences, including cardiovascular (CV) diseases (ischemic heart disease, heart failure, and strokes), CKD, disability, and death.1,2 In people with CKD, it is estimated that 90% are affected by hypertension (compared with 52.8% of people without CKD), a prognostic factor for progression to kidney failure, CV events, and increased mortality.3 Uncontrolled hypertension is systolic BP (SBP) >140 mm Hg and/or diastolic BP >90 mm Hg when an individual is not being treated with BP lowering medications, treated with insufficient number of medications, or failure to attain BP control with the use of ≥3 medications—i.e., resistance hypertension.2 Despite known adverse consequences of hypertension, a large population remains at risk or are unaware or not receiving adequate treatment.4 Data from over 4.2 million people screened for hypertension from 2017 to 2019 as part of the May Measurement Month program identified BP control among all hypertensives to range from 31% to 33.2% and were 53.7%–60% among those receiving medications.4 A bidirectional relationship between hypertension and CKD has been well-established with the risk of progressive elevation of BP often culminating in kidney failure.5 On the other hand, preexisting CKD can complicate management of hypertension, exacerbating the condition via multiple mechanisms, including salt and water retention, increased sympathetic axis drive, and renin-angiotensin-aldosterone-system activation. It is clinically imperative to attain good BP control in CKD as stipulated by multiple guideline recommendations.6,7 This is complicated by the fact that uncontrolled hypertension in CKD also results from low medication adherence due to numerous severely compromised kidney function, patient misconceptions, or misunderstanding about their care, polypharmacy, low affordability and a access to medications due to excessive cost, and low literacy levels.8 Strategies on achieving optimal BP control in CKD are desperately needed, including standalone interventions, that use self-management with patient-guided systems, self-monitoring with telemonitoring, or reminder systems that may improve adherence to treatment and clinical outcomes.7 Furthermore, interdisciplinary strategies for BP management including those involving nonphysician health care worker (pharmacist, nurses, etc.), telehealth strategies, and strategies that combine these systems are also needed as they have often led to improved patient outcomes.9,10 For example, a study of diabetes/CKD patients with uncontrolled hypertension randomized to telemonitoring and pharmacist intervention or usual care reported better BP control in intervention patients than patients in the usual care group (57.2% versus 30.0%; P = 0.001) at 6 and 12 months.9 Similarly, at 6 months of postintervention follow-up, BP control was significantly higher in the intervention than usual care group (71.8% versus 57.1%; P = 0.003).9 A recent systematic review of studies using telemonitoring and management support for BP management in patients with CKD (but excluding people receiving renal replacement therapy) showed significant reductions of SBP (−8.8 mm Hg; P = 0.02) and diastolic BP (−2.4 mm Hg; P < 0.001) as well as significant increase of eGFR (5.4 ml/min per 1.73 m2; P < 0.001).10 In this issue of Kidney360, Dopp and colleagues11 evaluated the effects of a fully virtual management system with usual nephrology care on BP control among Veterans Administration patients with difficult to manage hypertension and CKD. Patients with uncontrolled hypertension and referred for management to a nephrologist and a clinical pharmacist received a home BP monitor and instructions on how to use it. BP was measured daily at home and communicated over the phone, mailed in BP paper logs, or uploaded digitally using the home telehealth service before each appointment. The BP was managed through telephone visits conducted by the pharmacist every 4–12 weeks. The pharmacist, within approved scope of practice and nephrologist guidance as needed, adjusted BP medications to achieve recommended BP goals <130/80 mm Hg. The scope of practice for the pharmacist adjusting medications was limited to BP treatment-related factors (hypokalemia/hyperkalemia, potassium binders, potassium supplements, etc.). Patients with at least three phone visits and “objective” home BP measurements were included in the analysis where the primary outcome was change in SBP from baseline. Of the 116 patients referred to this clinic, 55 were eligible for inclusion in the analysis and mean change in SBP and diastolic BP between initial and final visit was −16±4 mm Hg and −6±7 mm Hg, respectively. Fewer patients had SBP ≥150 (P < 0.0002) and between 140 and 149 mm Hg (P = 0.02) at last visit compared with the initial visit, while 65%, 53%, and 44% of patients experienced ≥10, ≥15, and ≥20 mm Hg reductions in SBP, respectively, between initial and last clinic visit. This study provides two important messages: (1) effectiveness of telehealth (technology supported measurement of BP and transmission of results to care providers) services for BP management in CKD and (2) feasibility for involvement of nonphysician care team in the management of hypertension. Given the ubiquity of hypertension across all stages of CKD, telemonitoring and interdisciplinary strategies can be leveraged to improve BP control and medication adherence as it allows for close monitoring and medication intensification, reduces office visits, reduces management costs, and improves clinical outcomes, including CV outcomes and death. However, despite the known relationships between hypertension and CKD and documented benefits of telehealth and interdisciplinary strategies for BP management, there remains a paucity of information on telehealth and management support for hypertension in patients with CKD. The deficiency of robust evidence may be responsible for the lack of definite recommendations or suggestions on telemonitoring in recent Kidney Disease Improving Global Outcomes guideline.6 In the systematic review by Muneer and colleagues, only seven studies (three randomized controlled trials [RCTs]) with an overall sample of 821 participants met inclusion criteria.10 The lack of data may be related to barriers to adoption of telemonitoring for BP management, including cultural, structural, and financial, such factors need to be addressed to optimize and effectively draw from the benefits of telemonitoring and management support strategies.12 This study by Dopp and colleagues also reiterates the value of interdisciplinary approaches for optimal management of hypertension in CKD. Few kidney specialists are available in most countries to adequately manage CKD and associated comorbidities. The results from the Global Kidney Health Atlas of the International Society of Nephrology demonstrated critical global shortages in workforce capacity to care for patients with CKD.13 Interdisciplinary approaches as described in this study thus provide an opportunity to effectively manage common conditions such as hypertension in CKD by task shifting care to other health care workforce. In the Hyperlink 3 study,14 telehealth patients coordinated by pharmacists or a nurse-practitioner achieved similar mean BP reductions after 12 months of follow-up compared with usual clinic-based care with physicians (−19/−10 versus −18/−10 mm Hg, P = 0.45) suggesting the importance of interdisciplinary measures for hypertension control in CKD. Engagement of nonphysician health care workforce for BP management may be particularly useful in low-resource settings where the effect of shortages of physicians is more severe.13 As in this study, nonphysician health care workers should be adequately trained in BP management and empowered to add or adjust the doses of specific BP medications and complications related to medications use (e.g., hypo/hyperkalemia). Such approaches will be beneficial in reaching and providing care to underserved and remote populations with CKD and hypertension. Important limitations described in this study need to be fully addressed in future studies if the benefits of telemonitoring and/or interdisciplinary approaches are to be fully realized in patients with CKD and hypertension. First, large RCTs, designed with longer follow-up durations, and assessing CV, kidney, or mortality benefits are needed. Current ongoing RCTs in Canada (NCT04098354) and France (NCT02082093) have not been designed to address such gaps. In the systematic review described earlier, sensitivity analysis did not show eGFR benefits (5.5 ml/min per 1.73 m2; P = 0.12).10 The lack of demonstrable kidney benefits will make it difficult for telemonitoring and management support strategies to become adopted into practice given known implementation barriers, such as cost and infrastructure. Second, the data reported in this study are only for patients who met a certain threshold of home BP measurements, including nontelemonitored BP recordings, therefore creating a selection and reporting bias. As the management of BP in CKD is key to improving outcomes and reducing complications, studies using these strategies should use intention-to-treat approaches (including attrition and demography of patients for whom the process is unacceptable or who are unable to comply with the study measurement processes) in reporting the results. This may likely help to identify specific CKD populations for whom such strategies will be beneficial. Despite these limitations, Dopp and colleagues demonstrated the feasibility of BP control in people with CKD using telehealth, supported by nonphysician health care personnel. The objectives of future studies need to raise the bar by conducting RCTs; studies of patients receiving renal replacement therapy; studies with CV, kidney, and mortality end points; as well as in populations with geographic challenges living in rural/remote communities.

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