Recognition and Management of Resistant Hypertension

Clin J Am Soc Nephrol. 2017 Mar 7;12(3):524-535. doi: 10.2215/CJN.06180616. Epub 2016 Nov 28.


Despite improvements in hypertension awareness and treatment, 30%-60% of hypertensive patients do not achieve BP targets and subsequently remain at risk for target organ damage. This therapeutic gap is particularly important to nephrologists, who frequently encounter treatment-resistant hypertension in patients with CKD. Data are limited on how best to treat patients with CKD and resistant hypertension, because patients with CKD have historically been excluded from hypertension treatment trials. First, we propose a consistent definition of resistant hypertension as BP levels confirmed by both in-office and out-of-office measurements that exceed appropriate targets while the patient is receiving treatment with at least three antihypertensive medications, including a diuretic, at dosages optimized to provide maximum benefit in the absence of intolerable side effects. Second, we recommend that each patient undergo a standardized, stepwise evaluation to assess adherence to dietary and lifestyle modifications and antihypertensive medications to identify and reduce barriers and discontinue use of substances that may exacerbate hypertension. Patients in whom there is high clinical suspicion should be evaluated for potential secondary causes of hypertension. Evidence-based management of resistant hypertension is discussed with special considerations of the differences in approach to patients with and without CKD, including the specific roles of diuretics and mineralocorticoid receptor antagonists and the current place of emerging therapies, such as renal denervation and baroreceptor stimulation. We endorse use of such a systematic approach to improve recognition and care for this vulnerable patient group that is at high risk for future kidney and cardiovascular events.

Keywords: Antagonists; Antihypertensive Agents; Denervation; Humans; Life Style; Mineralocorticoid Receptor; Pressoreceptors; Renal Insufficiency, Chronic; blood pressure; cardiovascular disease; chronic kidney disease; diuretics; hypertension; kidney; renal denvervation; sodium intake.

Publication types

  • Review

MeSH terms

  • Antihypertensive Agents / therapeutic use
  • Coronary Vasospasm / complications
  • Coronary Vasospasm / diagnosis*
  • Coronary Vasospasm / epidemiology
  • Coronary Vasospasm / therapy*
  • Diet
  • Diuretics / therapeutic use
  • Drug Therapy, Combination
  • Electric Stimulation Therapy
  • Humans
  • Hypertension / complications
  • Hypertension / diagnosis*
  • Hypertension / epidemiology
  • Hypertension / therapy*
  • Life Style
  • Mineralocorticoid Receptor Antagonists / therapeutic use
  • Patient Compliance*
  • Renal Insufficiency, Chronic / complications*
  • Sympathectomy


  • Antihypertensive Agents
  • Diuretics
  • Mineralocorticoid Receptor Antagonists

Supplementary concepts

  • Hypertension Resistant to Conventional Therapy