Kidney Week 2025 Annual Meeting-Resistant Hypertension: Newer Therapies

Video Transcription

Video Summary

This session reviews modern evaluation and management of resistant hypertension, emphasizing its high prevalence (about 10–20% of hypertensive adults and even higher in CKD). Resistant hypertension is defined as blood pressure above goal despite three complementary drugs (ACEi/ARB + long‑acting dihydropyridine CCB + thiazide/thiazide‑like diuretic) at maximally tolerated doses, or controlled BP requiring four or more agents. In CKD, prevalence rises as eGFR falls and is linked to worse outcomes (stroke, heart failure, death, kidney failure).<br /><br />Speakers stress confirming “true” resistant hypertension by excluding pseudoresistance (improper measurement, white coat effect, nonadherence, undertreatment) and evaluating secondary causes (especially OSA and primary aldosteronism) plus medication/substance contributors (NSAIDs, decongestants, caffeine, antidepressants). Lifestyle measures—particularly sodium restriction—remain foundational.<br /><br />Pharmacologic escalation follows a stepwise approach: optimize core triple therapy, favor thiazide‑like agents (e.g., chlorthalidone; effective even in stage 4 CKD per CLICK), then add mineralocorticoid receptor antagonists (spironolactone supported by PATHWAY‑2). In CKD, MRAs require careful potassium and kidney monitoring; potassium binders (AMBER) can improve tolerability.<br /><br />The session highlights emerging therapies. Aldosterone synthase inhibitors (e.g., baxdrostat, lorundrostat) show ~9–11 mmHg systolic reductions in trials but may still cause hyperkalemia, with CKD data pending. Endothelin receptor antagonism (aprocitentan) lowers BP—especially nocturnal BP—and albuminuria, but edema is a key limitation; it received FDA approval (2024) at a lower dose. RNA-based angiotensinogen silencing (zilebesiran) produces months-long BP lowering after injection, with concerns about reversibility and typical RAAS-blockade adverse effects (e.g., hyperkalemia/AKI).

Asset Subtitle

Moderator(s): Nisha Bansal, Dinesh Khullar

Presentation(s):

Approach to Patients with Resistant Hypertension: What Is in Our Toolbox? - Nisha Bansal
Aldosterone Synthase Inhibitors: New Kids on the Block - Vivek Bhalla
Endothelin Antagonists for Resistant Hypertension - Jordana Cohen
RNA-Based Angiotensinogen Inhibitors: A Promising New Treatment? - James Luther

ASN thanks the American Heart Association Council on the Kidney in Cardiovascular Disease for assistance with this session.

Meta Tag

Date 11/6/2025

Pathway 1 Hypertension and Cardiorenal Disorders

Pathway 2 Pharmacology

Session ID 511908

Keywords

resistant hypertension

chronic kidney disease (CKD)

pseudoresistance

white coat hypertension

blood pressure measurement

medication nonadherence

secondary hypertension

obstructive sleep apnea (OSA)

primary aldosteronism

sodium restriction

chlorthalidone

mineralocorticoid receptor antagonists

spironolactone

aldosterone synthase inhibitors

zilebesiran