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Blood Pressure JNC -8 ACC/AHA 2017 B “* ” “ ” 0/< 8C Normal Normal Uver - “" ” a 0-129/<8C “Pre Elevated s hypertension” . 0-139/80-8! Stage 1 HTN Angiotensinogen ks ' . / N JC ole ) ! gkl iz sl Stage 1 HTN | Stage 2 HTN Decreasein o Renin renal perfusion . &' _ o (juxtaglomerular ,_ o a apparatus) . 50/2 100 Stage 2 HTN | Stage 2 HTN : ' e v Kidn S O )& BCO Jale[z]e e | D2 I/ : - ' Restrict salt intake & | CPVOX'lma'd Loop of Corln)\:cs)tI::ed Collecting - Lose weight DI SHIVERILS Henle Duct Quit smoking Tubule Tubule Lifestyle modification 5 5 (throughout treatment) Reduce Stress Reabsorption Solution Reabsorption [ Be physically active & Secretion concentration & Secretion [ | | General population Diabetes CKD Carboni (no diabetes or CKD) (no CKD) (with or without diabetes) aroonic n 3 1 Afferent nsais Anhydrase o arteriole P28 PGE; oy oy iy Thiazides BP goal BP goal BP goal Vas odilators 1oItors age <60: <140/90 <140/90 <140/90 4 age 260: <150/90 all ages all ages T ] nonblack | black 1 l All races Aldosterone antagonists Thiazide, ACE inhibitor, or ARB or calcium Thiazide or calcium channel blocker ACE inhibitor or ARB alone or in Efierc.’nt Vasou':::"(:nm channel blocker alone or in combination* alone or in combination combination with other drug classes* arteriole : Cortex T — | | A st s\ - L raraalranitss S, B K s resses I Select one of these treatment strategies: Outer Medulla : l I Ascending Vasopressin oz o . Add a second drug to a moderate dose of Start with two drugs separately or in fixed- Limb Maximize ;lr:etc:r:::;f:re adding first drug and titrate both up to maximum dose combination and titrate both up to ADH . dosage rlf needed maximum doslage if needed antagon ists 4 Ifneeded Add a drug from another class (beta-blocker, alpha blocker, centrally-acting drug, aldosterone antagonist i Distal . Proximal Loop of Collecting Glomerulus Convoluted Convoluted Henle Duct Tubule Tubule f Sympathetic \ N > P & activity @—s Secretion from Reabsorption Solution Reabsorption - . an organ . 2 . : i e & Secretion concentration & Secretion J . Na- signal Lungs ‘“’4 e ': K- = = =p Inhibitory signal = Live ! wueaap Tubular Na* CH L Carbonic iver ul ° - —p Hesction Surtace of pukmonary OB reabsorption and K C=tr> Afferent NsAIDs Anhydrase . excretion. H,0 retention O-++» ——p Active transport . iazi ACE ‘o a " arteriole PGl & PGE; 0y Thiazides N 2 ‘@ = = =p Passive transport Vasodilators | 1111DITOrS ‘u P Adrenal gland: » l 4 - cortex . Angiotensinogen s Angiotensin 1 Angiotensin Il = === === -2 Aldosterone N i secretion Water and salt g v retention. Effective ENaC Aldosterone Decrease in Renin ' circulating volume B renal perfusion . @ 'y increases. Perfusion ” — (Aldosterone) antagonists ()uxtaglomemlar. A : - @ Arteriolar richered, e iz ffemfllt Vasoco:ftrl ctor by V meees - ' pparatus increases. arteriole : k¢ _— ] increase in blood : e ncets o diuretics N\ L s | S K ..... Cortex .: "' pressure Arteriole H Outer Medulla : Kidney . A : : P ( 4‘—0ADH secretion = Ascending Vasopressin * ° Pituitary gland : : Limb Limb Trigger signal: S : ADH v § antagonists Collecting duct: - |Ow BP! H0 ablsn;p;on P HW) : L o ey ey g S g A S [ A —— : Urine / V3 5, ” Renal tubule cell Aldosterone f "-- ' ’ MR: Mineralocorticoid ‘ : Apical Basolateral receptor . Kid ' ENaC membrane membrane L,, . M‘ ney . [ Na'/K* s Lungs : Na* ' <K ® 1o P Na'/K' ATPase Uver -- ENaC Na*/K*ATPase of pulmonary . . T i T : | endothelium: ' ' expression expresion g © ™ : : Aldosterone + MR : : Aldosterone receptor M ' antagonists Angiotensinogen Angiotensin Il = = - BB . 9 . . . : " Decrease in . Renin = renal perfusion A &' _ o 2 % (juxtaglomerular ,_ o s 8 -- apparatus) N '. ' M ] e : s ' M [ s+ Kidney . M ' M - - =p