Treatment and Control of Hypertension Among Adults With Chronic Kidney Disease, 2011 to 2019

Abstract

BACKGROUND
Hypertension frequently accompanies chronic kidney disease (CKD) as etiology and sequela. We examined contemporary trends in hypertension treatment and control in a national sample of adults with CKD.

METHODS
We evaluated 5% cross-sectional samples of adults with CKD between 2011 and 2019 in the Veterans Health Administration. We defined CKD as a sustained estimated glomerular filtration rate value <60 mL/min per 1.73 m ² or a urine albumin-to-creatinine ratio ≥30 mg/g. The main outcomes were blood pressure (BP) control, defined as a systolic BP <140 mm Hg and a diastolic BP <90 mm Hg based on the mean of monthly BP measurements, and prescriptions for antihypertensive medications.

RESULTS
The annual samples ranged between n=22 110 and n=33 039 individuals, with a mean age of 72 years, 96% of whom were male. Between 2011 and 2014, the age-adjusted proportion of adults with controlled BP declined from 78.0% to 72.2% ( P value for linear trend, <0.001), reached a nadir of 71.0% in 2015, and then increased to 72.9% by 2019 ( P value for linear trend, <0.001). Among adults with BP above goal, the age-adjusted proportion who did not receive antihypertensive treatment increased throughout the decade from 18.8% to 21.6%, and the age-adjusted proportion who received ≥3 antihypertensive medications decreased from 41.8% to 36.3%. Prescriptions for first-line antihypertensive agents also decreased.

CONCLUSIONS
Among adults with CKD treated in the Veterans Health Administration, the proportion with controlled BP declined between 2011 and 2015 followed by a modest increase, coinciding with fewer prescriptions for antihypertensive medications.

Full text

Hypertension
Hypertension is available at www.ahajournals.org/journal/hyp
Hypertension. 2023;80:2533–2543. DOI: 10.1161/HYPERTENSIONAHA.123.21523 December 2023 2533
Correspondence to: Manjula Kurella Tamura, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304. Email mktamura@stanford.edu
Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/HYPERTENSIONAHA.123.21523.
For Sources of Funding and Disclosures, see page 2542.
© 2023 American Heart Association, Inc.
ORIGINAL ARTICLE
Treatment and Control of Hypertension Among
Adults With Chronic Kidney Disease, 2011 to 2019
Joshua D. Martinez, I-Chun Thomas, Maria E. Montez-Rath , Alan C. Pao, Enrica Fung , Vivek Charu , John J. Sim ,
Jaejin An , Michelle C. Odden , Manjula Kurella Tamura
BACKGROUND: Hypertension frequently accompanies chronic kidney disease (CKD) as etiology and sequela. We examined
contemporary trends in hypertension treatment and control in a national sample of adults with CKD.
METHODS: We evaluated 5% cross-sectional samples of adults with CKD between 2011 and 2019 in the Veterans Health
Administration. We defined CKD as a sustained estimated glomerular filtration rate value <60 mL/min per 1.73 m2 or a
urine albumin-to-creatinine ratio ≥30 mg/g. The main outcomes were blood pressure (BP) control, defined as a systolic
BP <140 mm Hg and a diastolic BP <90 mm Hg based on the mean of monthly BP measurements, and prescriptions for
antihypertensive medications.
RESULTS: The annual samples ranged between n=22 110 and n=33 039 individuals, with a mean age of 72 years, 96% of whom
were men. Between 2011 and 2014, the age-adjusted proportion of adults with controlled BP declined from 78.0% to 72.2%
(P value for linear trend, <0.001), reached a nadir of 71.0% in 2015, and then increased to 72.9% by 2019 (P value for linear
trend, <0.001). Among adults with BP above goal, the age-adjusted proportion who did not receive antihypertensive treatment
increased throughout the decade from 18.8% to 21.6%, and the age-adjusted proportion who received ≥3 antihypertensive
medications decreased from 41.8% to 36.3%. Prescriptions for first-line antihypertensive agents also decreased.
CONCLUSIONS: Among adults with CKD treated in the Veterans Health Administration, the proportion with controlled BP declined
between 2011 and 2015 followed by a modest increase, coinciding with fewer prescriptions for antihypertensive medications.
(Hypertension. 2023;80:2533–2543. DOI: 10.1161/HYPERTENSIONAHA.123.21523.) • Supplement Material.
Key Words: blood pressure ◼ health services ◼ hypertension ◼ renal insufficiency, chronic
See Editorial, pp 2544-2546
The identification and appropriate treatment of
hypertension is a public health priority to reduce
cardiovascular mortality and morbidity. Hyperten-
sion frequently accompanies chronic kidney disease
(CKD) and increases in prevalence with advancing CKD,
exceeding 80% among patients with late CKD.1 More-
over, patients with CKD are at higher risk for cardio-
vascular events and death.2 Consequently, hypertension
management constitutes the foundation of cardiovascu-
lar risk reduction in this high-risk population.
Several professional groups have issued clinical
practice guidelines for blood pressure (BP) targets and
preferred antihypertensive agents for people with CKD.3–
5 As the evidence base to support a benefit of treatment
has expanded, the definition of hypertension has evolved
so that more individuals are eligible for treatment. Yet,
data from the National Health and Nutrition Examina-
tion Survey suggest that control of BP has declined in
the general population over the past decade, reversing
improvements in BP control over the previous decade.6,7
For example, the proportion of US adults with hyperten-
sion who have controlled BP, defined as a systolic BP
<140 mm Hg and a diastolic BP <90 mm Hg, declined
from 53% between 2009 and 2012 to 48% between

Martinez et al Trends in Hypertension Control in CKD
ORIGINAL ARTICLE
2534 December 2023 Hypertension. 2023;80:2533–2543. DOI: 10.1161/HYPERTENSIONAHA.123.21523
2017 and 2020.7 A decline in BP control could reflect
reduced access to care or adoption of higher BP targets
as recommended by panel members from the Eighth
Joint National Committee on hypertension in 2014.8
On the other hand, a study of insured adults with CKD
found that rates of BP control were stable over the past
decade.9 Apart from this study, contemporary trends in
hypertension treatment and control among people with
CKD have not been examined in detail.
To address this knowledge gap, we evaluated tempo-
ral trends in recognition, treatment, and control of hyper-
tension among adults with CKD in the Veterans Health
Administration (VA), the nation’s largest integrated health
system. We hypothesized that rates of BP control have
been stable or improved over time and that guideline
concordant therapy has become more frequent in the VA
CKD population.
METHODS
Study Design and Data Source
We conducted a serial cross-sectional analysis using data
from the VA between 2011 and 2019. Data sources included
enrollment files, outpatient encounters, vital signs, labora-
tory data, pharmacy records, and medical claims. The study
was approved by the Stanford University Institutional Review
Board and the VA Palo Alto Health Care System’s office of
Research and Development and followed the Strengthening
the Reporting of Observational Studies in Epidemiology guide-
lines for cohort studies. A limited data set that supports the
findings of this study is available from the corresponding
author pursuant to a written request with appropriate approv-
als and assurances to maintain data in accordance with secu-
rity requirements.
Population
We assembled annual period prevalent 5% samples of
Veterans with CKD between 2011 and 2019. We identified
Veterans with CKD in each calendar year, based on the Kidney
Disease Improving Global Outcomes criteria: (1) a sustained
estimated glomerular filtration rate value <60 mL/min per 1.73
m2 for at least 90 days or (2) a urine albumin-to-creatinine ratio
(UACR) ≥30 mg/g.10 We estimated GFR with the 2021 CKD
Epidemiology Collaboration equation using serum creatinine,
age, and sex.11 We excluded individuals who initiated dialysis or
received a kidney transplant during the calendar year and indi-
viduals with fewer than 2 outpatient BP measurements at least
90 days apart during the calendar year. We took a 5% sample
of those with low estimated glomerular filtration rate and a 5%
sample of those with albuminuria in each year, yielding an ana-
lytic cohort of n=238 748 (Figure S1).
Patient Characteristics
We ascertained age in the calendar year, sex, and race/eth-
nicity (non-Hispanic White, non-Hispanic Black, Hispanic, and
other) from enrollment files. We recorded weight, height, and
body mass index closest to the index (first) BP measurement.
We ascertained comorbidities with International Classification of
Diseases, Ninth Revision, Clinical Modification and International
Statistical Classification of Diseases and Related Health
Problems, Tenth Revision, Clinical Modification diagnosis codes
from inpatient and outpatient encounters during the calendar
year.
NOVELTY AND RELEVANCE
What Is New?
In serial cross-sectional samples of adults with chronic
kidney disease between 2011 and 2019 treated in the
Veterans Health Administration, this study demonstrates
a 7% age point decline in the proportion with controlled
blood pressure, defined as a systolic blood pressure
<140 mm Hg and a diastolic blood pressure <90 mm Hg
during the first half of the decade, followed by a 2% age
point improvement from 2015 to 2019. The decline in
blood pressure control coincided with fewer prescriptions
for blood pressure medications, including preferred first-
line antihypertensive agents and multidrug regimens.
What Is Relevant?
High blood pressure affects up to 80% of adults with
chronic kidney disease. The evidence base to support
a benefit of high blood pressure treatment in this pop-
ulation has expanded in recent years.
Clinical/Pathophysiological Implications?
This study highlights opportunities to improve the deliv-
ery of guideline-recommended care for hypertension
in patients with chronic kidney disease, a population
at high risk for cardiovascular morbidity and mortality.
Nonstandard Abbreviations and Acronyms
ACCORD Action to Control Cardiovascular Risk in
Diabetes
ACE angiotensin-converting enzyme
ARB angiotensin receptor blocker
BP blood pressure
CKD chronic kidney disease
DoD Department of Defense
SPRINT Systolic Blood Pressure Intervention Trial
UACR urine albumin-to-creatinine ratio
VA Veterans Health Administration

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Trends in Hypertension Control in CKDMartinez et al
BP Control, Hypertension Diagnosis, and Use
of Antihypertensive Medications
All BP measurements obtained during outpatient visits at VA
medical facilities were recorded in the data set. We recorded the
last BP measurement in each month of the calendar year and
calculated the average annual BP.12 When multiple BP measure-
ments were available on a single day, we recorded the lowest
value to avoid white-coat hypertension. We defined controlled
BP at the patient level, based on the average annual BP, using
the VA/Department of Defense (DoD) 2014 CKD practice
guideline target of a systolic BP <140 mm Hg and a diastolic
BP <90 mm Hg.13 In complementary analyses, we defined BP
control using the updated 2020 VA/DoD guideline target of a
systolic BP <130 mm Hg.3 We ascertained recognition of hyper-
tension on the basis of International Classification of Diseases,
Ninth Revision, Clinical Modification (401.x–405.x) or International
Classification of Diseases, Tenth Revision, Clinical Modification
(I10–I15) diagnosis codes during the calendar year. We identified
antihypertensive medication use by dispensation of medications
totaling ≥90 days during the calendar year. We defined concomi-
tant antihypertensive medication use if there was an overlap of
≥7 days for the number of days an individual was supplied a dif-
ferent class of medications during the index BP measurement
(ie, the last BP measurement in the first month). Antihypertensive
medications were classified into the following categories: thiazide-
type diuretic, loop diuretic, ACE (angiotensin-converting enzyme)
inhibitor, angiotensin receptor blocker (ARB), β-blocker, calcium
channel blocker, potassium-sparing diuretic, mineralocorticoid
receptor antagonist, α-blocker, direct vasodilators, or centrally
acting agents. We assessed the use of ACE inhibitors or ARBs
and use of thiazide-type diuretics for the entire cohort and in sub-
groups defined by BP control, age group, race, diabetes, UACR,
and CKD stage. We selected these agents based on guidelines
recommending an ACE inhibitor or ARB as preferred agents for
those with albuminuria or for all individuals with CKD.3–5 Thiazide-
type diuretics are recommended as first-line agents by multiple
guidelines, including those from the VA/DoD.3
Statistical Analysis
For each year, we estimated the age-adjusted mean systolic
and diastolic BP level, and the age-adjusted distribution of BP,
using systolic BP categories of <110, 110 to 119, 120 to 129,
130 to 139, 140 to 149, and ≥150 mm Hg and diastolic BP
categories of <60, 60 to 79, 80 to 89, and ≥90 mm Hg. We
also estimated the age-adjusted proportion of controlled BP
overall and in subgroups by stage of CKD by year. Among all
Veterans and among those with uncontrolled BP, we estimated
the age-adjusted proportion of hypertension recognition and
Table 1. Demographic Characteristics of 5% Samples of Adults With CKD in the Veterans Health Administration From 2011 to 2019
Characteristic
Year
2011
(n=22 110)
2012
(n=21 271)
2013
(n=21 043)
2014
(n=23 727)
2015
(n=25 258)
2016
(n=27 118)
2017
(n=28 331)
2018
(n=29 952)
2019
(n=33 039)
Age±SD, y 72±11 72±11 72±11 72±11 72±11 72±11 72±11 72±11 72±10
Age group, y (%)
<60 13.0 12.8 12.7 13.0 11.9 11.4 10.9 10.8 10.8
60–69 33.2 35.5 35.8 36.6 36.8 36.4 33.6 29.4 26.2
70–79 26.1 25.3 25.1 25.2 26.4 28.0 32.3 37. 3 41.4
≥ 80 27. 7 26.5 26.5 26.1 24.9 24.3 23.2 22.5 21.6
Male, % 97. 2 97 96.8 96.6 96.5 96.3 96.2 96.1 95.8
Race, %
White 71.7 71.7 71.1 71 71 70.7 70.4 70.6 69.8
Black 1 7. 9 18.4 19.5 20.2 20.2 20.8 20.7 21.0 21.5
Other 7. 9 8.0 8.0 7.6 7. 9 7. 6 8.0 7. 7 8.0
Missing 2.5 1.9 1.5 1.2 1.0 0.8 0.9 0.7 0.7
Hispanic ethnicity, % 3.4 3.9 4.1 5.4 5.8 5.5 5.4 5.7 5.6
Diabetes, % 64.4 66.0 66.8 6 7. 6 68.4 68.6 68.8 68.0 67. 3
Ischemic heart disease, % 2.9 3.0 3.2 2.9 2.7 2.8 3.3 3.5 3.3
Heart failure, % 16.2 16.7 17. 1 1 7. 0 16.5 14.9 14.5 13.5 14.7
Body mass index±SD, kg/m230.8±6.4 30.9±6.4 31.0±6.4 31.0±6.5 31.1±6.5 31.0±6.4 31.2±6.5 31.1±6.4 31.0±6.4
CKD stage, %
1–2 22.3 23.5 23.4 23.8 24.7 23.8 23.8 24 24.1
3 69.5 68.3 68.8 68.3 6 7. 7 69 68.8 68.5 67.8
4 7.1 7. 2 6.7 6.8 6.5 6.4 6.5 6.3 6.4
5 1.1 1.1 1.1 1.1 1.1 0.9 0.9 1.2 1.6
UACR±SD, mg/g 227±596 250±650 258±637 260±644 258±602 266±633 277±639 263±608 272±632
Missing values for body mass index were present in 19% to 21% of the sample and for UACR in 38% to 47% of the sample. CKD indicates chronic kidney disease;
and UACR, urine albumin-to-creatinine ratio.

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2536 December 2023 Hypertension. 2023;80:2533–2543. DOI: 10.1161/HYPERTENSIONAHA.123.21523
Table 2. Age-Adjusted Proportion of Adults in the Veterans Health Administration With Controlled BP
BP target 2011 2012 2013 2014 2015 2016 2017 2018 2019 Ptrend
2014 VA/DoD guideline: BP<140/90 mm Hg
Controlled BP overall, % 78.0 76.3 75.2 72.2 71.0 71.4 71.3 72.5 72.9 *†
Controlled BP by subgroups
Age group, y
<60 74.3 72.6 72.0 71.6 69.1 70.7 70.2 72.1 73.1 *†
60–69 77. 0 75.4 74.6 70.6 70.0 70.8 70.3 71.4 72.3 *†
70–79 79.4 77. 2 75.9 73.6 72.5 72.5 72.3 73.8 73.9 *†
≥ 80 79.4 78.0 76.4 73.0 71.3 71.1 71.9 72.4 72.4 *†
Race
White 79.8 77. 8 76.9 73.9 72.8 73.3 72.9 74.3 74.6 *†
Black 71.3 70.2 69.4 66.1 64.0 65.4 66.3 6 7. 0 6 7. 8 *†
Other 76.7 76.0 73.8 72.8 71.0 70.3 70.3 71.2 72.2 *†
Diabetes, %
Yes 77. 5 75.6 74.3 71.1 69.8 70.7 70.1 72.0 72.3 *†
No 79.1 77. 5 7 7. 0 74.6 73.5 73.0 73.9 73.5 74.0 *
UACR, %*
<30 mg/g 8 7. 3 85.7 83.2 83.7 82.1 82.0 82.6 81.7 82.4 *
30–299 mg/g 77. 6 76.0 74.8 72.3 70.7 70.3 71.5 72.9 73.7 *†
≥ 300 mg/g 62.4 60.9 60.7 57.4 54.9 57. 0 54.5 58.8 5 7. 6 *†
CKD stage, %
1–2 74.4 72.4 71.5 69.3 6 7. 7 6 7. 3 6 7. 3 69.3 70.4 *†
3 79.9 78.2 77. 1 73.7 73.1 73.6 73.5 74.5 74.5 *†
4 72.1 71.6 70.1 68.5 63.6 64.6 64.0 65.4 6 7. 1 *
5 73.2 68.9 63.6 62.0 55.6 58.9 61.6 59.9 65.6 *†
2020 VA/DoD guideline: systolic BP<130 mm Hg
Controlled BP overall, % 47. 4 45.9 44.1 41.6 40.3 40.5 40.4 41.5 41.8 *†
Controlled BP by subgroups
Age group, y
<60 46.5 44.7 42.4 43.5 40.7 40.9 42.4 43.4 43.3 *†
60–69 47. 0 45.1 43.4 39.7 39.7 39.6 39.4 40.5 40.5 *†
70–79 47. 9 46.9 43.5 41.9 39.9 40.7 39.9 41.2 42.0 *†
≥ 80 47. 9 46.8 46.3 43.2 41.2 41.5 41.5 42.4 42.2 *
Race
White 49.2 47. 3 45.6 43.5 41.8 42.2 42.2 43.2 43.5 *†
Black 40.0 40.4 38.2 34.6 34.8 35.0 34.4 36.3 36.7 *†
Other 46.2 45.6 43.8 42.1 39.7 40.3 40.3 40.6 40.9 *†
Diabetes, %
Yes 46.8 45.0 42.6 39.9 38.5 39.0 38.4 40.1 40.5 *†
No 48.6 48.0 47. 2 45.4 44.0 43.9 44.8 44.3 44.1 *
UACR, %‡
<30 mg/g 59.4 56.1 54.2 51.8 52.1 51.6 53.2 51.6 52.7 *
30–299 mg/g 45.4 44.4 42.1 40.5 38.4 38.0 38.2 40.2 40.7 *†
≥ 300 mg/g 28.9 29.3 2 7. 2 23.8 22.9 24.2 23.1 25.9 24.8 *†
Controlled BP by CKD stage, %
1–2 41.9 40.8 38.8 36.2 34.1 34.8 34.0 36.2 36.7 *†
3 49.8 48.2 46.4 44.0 43.2 42.9 43.2 44.0 44.2 *†
4 42.2 42.5 39.8 38.6 34.7 36.9 35.3 35.2 36.8 *
5 40.5 39.0 36.4 30.2 28.3 31.3 33.2 38.6 36.0 *†
BP indicates blood pressure; CKD, chronic kidney disease; DoD, Department of Defense; UACR, urine albumin-to-creatinine ratio; and
VA, Veterans Affairs.
*P value for linear trend between 2011 and 2014, <0.05.
†P value for linear trend between 2015 and 2019, <0.05.
‡Among those with nonmissing UACR.

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Trends in Hypertension Control in CKDMartinez et al
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2011 2012 2013 2014 2015 2016 2017 2018 2019
Age-adjusted proportion (%)
Year
2014 VA/DoD BP goal 2020 VA/DoD BP Goal
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2011 2012 2013 2014 2015 2016 2017 2018 2019
Age-adjusted proportion (%)
Year
ACEI or ARB prescription Thiazide prescription
Figure. Trends in blood pressure (BP) control between 2011 and 2019 among adults with chronic kidney disease treated in the
Veterans Health Administration (VA).
A, Age-adjusted proportion of adults with controlled blood pressure based on 2014 and 2020 VA/Department of Defense (DoD) guidelines.
B, Age-adjusted proportion of adults with filled prescription for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers
and filled prescription for thiazide diuretic. A, The 2014 VA/DoD guidelines recommended a BP goal <140/90 mm Hg. The 2020 VA/DoD
guidelines recommended a systolic BP goal <130 mm Hg. The data markers represent the age-adjusted observed proportion with BP control.
The line segments were generated using joinpoint regression with a change at 2015. Applying the 2014 BP goals, BP control from 2011
to 2014 yielded a P<0.001; BP control from 2015 to 2019 yielded a P<0.001; the test for difference in trend lines before and after 2015
yielded a P<0.001. Applying the 2020 BP goals, BP control from 2011 to 2014 yielded a P<0.001; BP control from 2015 to 2019 yielded a
P<0.001; the test for difference in trend lines before and after 2015 yielded a P<0.001. B, ACE (angiotensin-converting enzyme) inhibitor and
angiotensin receptor blocker (ARB) data markers represent the age-adjusted observed proportion with a prescription. The line (Continued )

Martinez et al Trends in Hypertension Control in CKD
ORIGINAL ARTICLE
2538 December 2023 Hypertension. 2023;80:2533–2543. DOI: 10.1161/HYPERTENSIONAHA.123.21523
antihypertensive medication use. We examined prescriptions for
specific antihypertensive medications in the entire cohort and
within subgroups. We present descriptive statistics (percent-
ages, mean [SD], and median [Q1–Q3]) by calendar year. We
estimated age-adjusted proportions using marginal probabilities
from age-adjusted logistic regression models using the margins
command in Stata.14 We used stratified models for subgroup
analyses, which allows proportions to vary between subgroups.
We assessed linear trends before and after the publication of
the Eighth Joint National Committee guidelines, between 2011
and 2014 and between 2015 and 2019, using piecewise lin-
ear regression.15 In sensitivity analyses, we assessed controlled
BP using the mean of all outpatient BP values for each patient,
rather than the mean of the monthly BP measurements. We
performed all analyses using a combination of SAS Enterprise
Guide, version 8.4 (SAS Institute, Inc, Cary, NC), and Stata, ver-
sion 17.0 (StataCorp LLC, College Station, TX).
RESULTS
Baseline Characteristics
Characteristics of adults with CKD in the period preva-
lent samples with CKD are presented in Table 1. Between
2011 and 2019, the mean age of patients was 72
years, and the majority were male and White. During this
period, the proportion of patients who identified as Black
increased from 17.9% to 21.5%, the proportion who iden-
tified as Hispanic ethnicity increased from 3.4% to 5.6%,
and the proportion with diabetes increased from 64.4%
to 67.3%. Among those with UACR measurement, the
mean UACR increased from 227 to 272 mg/g. The fre-
quency of advanced stages of CKD declined over time.
BP Trends
The mean±SD number of BP measurements per patient
per year was 5±3 and did not vary by year. Between
2011 and 2019, the age-adjusted mean annual sys-
tolic BP increased from 131 to 133 mm Hg and age-
adjusted mean annual diastolic BP increased from 71 to
73 mm Hg (Figure S2). When we applied the 2014 VA/
DoD BP goal of <140/90 mm Hg, we found that the
age-adjusted proportion with controlled BP was 78.0%
in 2011 (Table 2). In 2011, the proportion with controlled
BP was lower among adults aged <60 years and those
identified as Black compared with those identified as
White or other races. The proportion with controlled BP
was also lower in adults with diabetes, albuminuria, and
those with CKD stages 4 to 5. The proportion with con-
trolled BP declined between 2011 and 2014 (P value for
linear trend, <0.001), reached a nadir of 71.0% in 2015,
and then increased to 72.9% by 2019 (P value for linear
trend, <0.001; Figure [A]). Similar trends in controlled
BP were observed across all subgroups except for those
without diabetes, those without albuminuria (UACR, <30
mg/g), and those with stage 4 CKD (Table 2). When
we applied the 2020 VA/DoD BP target of systolic BP
<130 mm Hg, we found that 47.4% of patients achieved
BP control in 2011. The proportion with BP control
reached a nadir of 40.3% in 2015 and then increased
to 41.8% in 2019 (Figure [B]; Table 2). We found similar
results when we used the mean of all BP measurements
in a sensitivity analysis (Table S1).
Recognition of Hypertension and Medication Use
Among all adults with CKD, the age-adjusted proportion
with a diagnosis of hypertension was 93.1% in 2011,
remained stable between 2011 and 2014, and signifi-
cantly declined between 2015 and 2019 from 92.9%
to 89.7% (Table 3). Among the subgroup of adults with
uncontrolled BP based on the 2014 VA/DoD BP target,
there was a higher level of hypertension recognition, with
a similar pattern of decline over time. Among adults with
BP above goal, the age-adjusted proportion who did not
receive antihypertensive treatment increased through-
out the decade from 18.8% to 21.6% (P value for linear
trends, <0.001), and the age-adjusted proportion who
received ≥3 antihypertensive medications decreased
throughout the decade from 41.8% to 36.3% (P value
for linear trends, <0.001).
In 2011, the age-adjusted proportion of patients
who were prescribed an ACE inhibitor or ARB was
65.0% (Table 4). Prescription of ACE inhibitor or ARB
was higher among those with uncontrolled BP, younger
patients, non-White race, diabetes, albuminuria (UACR,
≥300 mg/g), and earlier stages of CKD. From 2011 to
2014 and from 2015 to 2019, prescription of ACE inhib-
itors or ARBs decreased (Figure [B]). Similar trends were
observed in most subgroups, except for those aged 70 to
79 years and those with CKD stage 5 among whom pre-
scription of ACE inhibitors or ARBs was <50% through-
out the decade.
In 2011, the age-adjusted proportion of patients who
were prescribed any thiazide-type diuretic was 24.1%
(Table 5). Thiazide-type prescriptions were more com-
mon in patients with uncontrolled BP, younger patients,
those of Black race, and those with diabetes and ear-
lier stages of CKD. From 2011 to 2014, prescriptions
of thiazide diuretics decreased overall and in most
subgroups. From 2015 to 2019, prescriptions of thia-
zide-type diuretics continued to decrease overall and
in selected subgroups, such as patients with age ≥80
Figure Continued. segments were generated using joinpoint regression with a change at 2015. ACE inhibitor or ARB prescriptions from
2011 to 2014 yielded a P<0.001; ACE inhibitor or ARB prescriptions from 2015 to 2019 yielded a P<0.001; the test for difference in trend
lines before and after 2015 yielded a P=0.04. Thiazide prescriptions from 2011 to 2014 yielded a P<0.001; thiazide prescriptions from 2015
to 2019 yielded a P<0.001; the test for difference in trend lines before and after 2015 yielded a P<0.001.

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Trends in Hypertension Control in CKDMartinez et al
years and those with diabetes. In contrast to the general
decline in prescriptions of any thiazide-type diuretic, the
age-adjusted proportion of patients who were prescribed
chlorthalidone increased from 2.5% in 2011 to 5.8% in
2019 (P<0.001).
DISCUSSION
In this study of adults with CKD treated at the VA
between 2011 and 2015, we found that BP control
declined 7 percentage points and then improved mod-
estly between 2015 and 2019. By 2019, 1 of 4 adults
with CKD did not meet the 2014 VA/DoD guidelines for
BP control, and >2 of 4 did not meet the level of BP con-
trol recommended by the 2020 VA/DoD guidelines and
other professional groups. These trends were observed
in most subgroups and were accompanied by fewer pre-
scriptions of preferred first-line antihypertensive agents
such as ACE inhibitors, ARBs, and thiazide-type diuretics
and less frequent multidrug antihypertensive regimens.
Our findings complement and extend previous studies
of BP control in the general adult US population by elu-
cidating BP trends and medication use in the high-risk
population of adults with CKD. Moreover, compared with
data obtained from the National Health and Nutrition
Examination Survey that uses 2-year sampling cycles
and has a small number of adults with advanced CKD,
the annual sampling frame and large sample enabled us
to examine secular changes in BP control in subgroups
with more precision.6,7 In relation to the sizable decrease
in antihypertensive medication prescriptions throughout
the decade, recognition of hypertension remained above
90% for most of the decade with a smaller absolute
decline over this period. These observations raise the
possibility that changes in BP control during the first half
of the decade in the Veteran CKD population were due
to the adoption of higher BP targets, rather than lack of
recognition or access to care. The adoption of higher BP
targets could reflect a provider concern for or response
to adverse events or patient and provider choice to
reduce medication burden.
Muntner et al6,7 found that BP control improved in the
general population from 1999 to 2008, reaching a pla-
teau between 2009 and 2014 before falling between
2015 and 2020. In the VA CKD sample, we found that
BP control declined between 2011 and 2015. There
were broad-based changes in hypertension practice
patterns in the VA CKD sample, evident in all patient
subgroups except for those under the age of 60 years.
Importantly, these changes appeared to predate the
2014 Eighth Joint National Committee panel member
report, suggesting that the report was likely not a cata-
lyst for change in BP management but rather a reflection
of widespread practice. The Eighth Joint National Com-
mittee report introduced a higher BP target of <150/90
mm Hg for patients above the age of 60 years, while it
notably maintained a BP target of <140/90 mm Hg for
adults with CKD, in line with BP guidelines from VA/
DoD and other professional groups.8,10,13 At the time,
the rationale for a higher BP target was based on lim-
ited trial evidence that supported a benefit of lowering
BP below 150/90 mm Hg in older adults and concern
that aggressive lowering of BP in frail individuals would
exacerbate polypharmacy and increase adverse events.
Table 3. Age-Adjusted Prevalence of Hypertension Recognition and Treatment Among Adults With CKD in the Veterans Health
Administration
2011 2012 2013 2014 2015 2016 2017 2018 2019 Ptrend
All adults with CKD n=22 110 n=21 271 n=21 043 n=23 727 n=25 258 n=27 118 n=28 331 n=29 952 n=33 039
Hypertension diagnosis code, % 93.1 93.0 93.2 93.1 92.9 92.9 92.8 89.7 89.7 *
Mean number of BP
medications±SD, %
2.1±0.01 2.1±0.01 2.1±0.01 2.0±0.01 2.0±0.01 1.9±0.01 1.9±0.01 1.9±0.01 1.9±0.01 *†
None 19.7 20.4 20.5 20.9 22.1 22.8 23.0 23.3 23.3 *†
1 drug 18.2 19.0 18.6 18.7 18.9 19.4 19.7 19.6 20.3 *†
2 drugs 22.4 22.1 22.5 22.4 22.4 22.4 22.4 22.7 22.1 ns
≥ 3 drugs 39.7 38.5 38.4 3 7. 9 36.5 35.4 34.8 34.3 34.3 *†
Adults with uncontrolled BP n=4875 n=5069 n=5241 n=6615 n=7354 n=7766 n=8131 n=8202 n=8894
Hypertension diagnosis code, % 9 7. 1 9 7. 5 9 7. 1 9 7. 3 97. 1 97. 4 96.8 94.3 94.3 *
Mean number of BP
medications±SD, %
2.2±0.02 2.2±0.02 2.1±0.02 2.1±0.02 2.1±0.02 2.0±0.02 2.0±0.02 2.0±0.02 2.0±0.02 *†
None 18.8 19.5 20.1 20.2 20.2 21.2 21.1 22.3 21.6 *†
1 drug 17. 5 18.4 18.1 18.0 17. 8 18.8 19.2 19.1 19.2 *
2 drugs 21.8 21.5 22.1 21.9 22.8 22.2 22.5 23.2 22.9 ns
≥ 3 drugs 41.8 40.6 39.7 40.0 39.1 37. 8 3 7. 2 35.4 36.3 *†
ns, P value for linear trends in both periods, >0.05. BP indicates blood pressure; and CKD, chronic kidney disease.
*P value for linear trend between 2015 and 2019, <0.05.
†P value for linear trend between 2011 and 2014, <0.05.

Martinez et al Trends in Hypertension Control in CKD
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2540 December 2023 Hypertension. 2023;80:2533–2543. DOI: 10.1161/HYPERTENSIONAHA.123.21523
Observational studies have reported an increased risk for
falls and other adverse events in real-world ambulatory
populations and nursing home residents when systolic
BP is lowered to <110 mm Hg with antihypertensive
treatment.16,17 Similar concerns have been raised about
the potential safety of lowering diastolic BP in people
with wide pulse pressure.18–20
On the other hand, SPRINT (Systolic Blood Pres-
sure Intervention Trial) and the ACCORD trial (Action
to Control Cardiovascular Risk in Diabetes) found no
increased risk of falls when systolic BP was lowered to
<120 mm Hg as compared with <140 mm Hg.21,22 Our
study demonstrates that less intensive antihypertensive
therapy and a lower frequency of low diastolic BPs come
at the expense of higher systolic BPs. Post hoc analyses
of SPRINT and ACCORD suggest that such a trade-off
is not warranted as there was no evidence that intensive
BP treatment increased adverse events in trial partici-
pants with low baseline diastolic BP.23,24 Whether these
results can be generalized to the broader population
remains a point of controversy, and current guidelines
still emphasize the importance of individualizing therapy
guided by patient tolerance.25,26
In our study, we document a decline in prescriptions
for ACE inhibitors and ARBs for patients who would ben-
efit the most from these medications. This prescribing
pattern may have been driven by risks for hyperkalemia
and acute kidney injury. Discontinuation of ACE inhibitor
or ARB therapy has been associated with poorer out-
comes.27 Furthermore, there is emerging evidence that
reinitiation of ACE inhibitors or ARBs after an acute kid-
ney injury event may be beneficial with cautious monitor-
ing.28 The perceived benefit of stopping ACE inhibitors
or ARBs may be incorrect, as the STOP-ACEi trial dem-
onstrated that discontinuation of ACE inhibitor did not
reduce the rate of kidney function decline or adverse
events in adults with stage 4 to 5 CKD.29 Finally, tri-
als of sodium-glucose cotransporter-2 inhibitors were
conducted with a background of ACE inhibitor or ARB
therapy; hence the potential maximum benefit of these
Table 4. Age-Adjusted Proportion With Filled Prescription for Angiotensin-Converting Enzyme
Inhibitors or Angiotensin Receptor Blockers
Patient characteristics 2011 2012 2013 2014 2015 2016 2017 2018 2019 Ptrend
Overall, % 65.0 64.8 63.7 62.9 62.7 61.7 61.9 61.1 59.7 *†
BP control
Controlled BP, % 63.8 63.4 61.9 60.8 60.4 59.3 59.2 58.5 57.1 *†
Uncontrolled BP, % 70.7 68.7 71.6 70.1 71.6 69.6 70.7 69.0 67. 0 †
Age group, y
<60 68.3 66.4 65.6 64.7 64.7 62.7 61.8 63.1 61.1 *†
60–69 71.2 71.2 70.6 69.4 69.3 68.0 68.4 66.8 64.5 *†
70–79 63.6 64.9 63.6 62.7 63.1 62.3 63.9 63.4 62.0 ns
≥ 80 56.2 54.9 53.1 53.1 52.2 51.6 50.3 49.1 48.6 *†
Race
White 63.9 63.9 62.8 62.3 62.3 61.1 61.5 60.7 59.4 *†
Black 68.9 67. 4 66.5 64.9 64.3 63.7 62.3 61.5 59.8 *†
Other 68.6 68.4 66.5 64.7 64.8 62.7 65.9 65.5 63.7 *†
Diabetes, %
Yes 73.2 72.6 71.4 70.8 69.9 69.3 69.4 68.6 66.9 *†
No 49.6 49.2 47. 8 46.3 4 7. 3 45.3 45.4 45.6 45.2 *
UACR, %‡
<30 mg/g 68.3 67. 8 64.4 62.8 63.7 62.6 61.9 59.3 57. 9 *†
30–299 mg/g 69.7 69.6 69.5 68.4 6 7. 2 66.4 66.6 65.2 64.1 *†
≥ 300 mg/g 77. 6 76.5 74.7 72.8 73.7 74.2 74.7 73.9 70.8 *†
CKD stage, %
1–2 69.5 70.8 70.8 69.2 68.5 67. 5 67. 8 6 7. 4 66.2 *†
3 64.2 63.9 62.2 61.7 61.4 60.2 60.8 59.9 58.5 *†
4 61.6 56.2 55.6 56.9 58.3 58.7 54.5 55.3 53.1 †
5 41.8 44.7 47.2 39.9 40.9 39.1 39.3 3 7. 7 41.6 ns
ns, P value for linear trends in both periods, >0.05. BP indicates blood pressure; CKD, chronic kidney disease; and UACR, urine
albumin-to-creatinine ratio.
*P value for linear trend between 2011 and 2014, <0.05.
†P value for linear trend between 2015 and 2019, <0.05.
‡Among those with nonmissing UACR.

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Trends in Hypertension Control in CKDMartinez et al
therapies may not be realized with current prescribing
patterns.
Several guidelines also recommend thiazide-type
diuretics as first-line agents for BP control and as a
strategy to mitigate risk for hyperkalemia associated
with ACE inhibitors and ARBs. Wider use of thiazides
may be limited by concerns about side effects, such as
electrolyte abnormalities and glucose intolerance, and
reduced efficacy in patients with low kidney function.
However, new data suggest the thiazide-type diuret-
ics such as chlorthalidone are effective for lowering
BP in advanced CKD.30 We found that prescriptions
for chlorthalidone nearly doubled, although overall pre-
scription for thiazide-type diuretics declined over time in
most subgroups, including those with uncontrolled BP or
stage 1 to 2 CKD. Taken together, these observations
highlight potential opportunities to improve BP control
in the VA with greater use of guideline-recommended
therapies among adults with CKD.
Over the past 2 decades, the VA has performed equally
well or better at delivering guideline-recommended care
for hypertension and chronic conditions compared with
other health care systems in the United States.31–33 To
achieve these results, the VA adopted numerous strat-
egies to address patient-, clinician-, and system-related
barriers to improved BP control.13 Rates of BP control
in the VA remain higher than those in the general US
population.6 The downtrend in BP control during the first
half of the previous decade is concerning because imple-
mentation of guideline-recommended BP targets is esti-
mated to reduce all-cause mortality by 4%, with a number
needed to treat to avert 1 death in adults with CKD of
39.34,35 We did detect, however, an uptick in control dur-
ing the second half of the decade, which could signal a
reversal. These trends warrant close attention as the VA
prepares to adopt lower BP targets recommended by the
2020 VA/DoD guidelines, while 2 major changes to the
VA are also underway, more reliance on telehealth and
hybrid models of health care following the COVID-19
pandemic and expansion of eligibility for VA health ben-
efits through the PACT Act. This legislation designates
hypertension as a service-connected condition following
Table 5. Age-Adjusted Proportion With Filled Prescription for Thiazide-Type Diuretics
Patient characteristics 2011 2012 2013 2014 2015 2016 2017 2018 2019 Ptrend
Overall, % 24.1 23.0 22.2 22.1 20.6 21.2 20.5 20.1 20.0 *†
BP control
Controlled BP, % 22.4 21.2 20.4 19.8 18.2 18.8 18.1 17. 6 17. 9 *†
Uncontrolled BP, % 30.3 28.9 27. 7 2 7. 9 26.4 2 7. 2 26.5 26.8 25.9 *
Age group, y
<60 26.5 26.7 24.6 25.4 22.7 22.1 23.4 21.8 22.1 *
60–69 28.5 26.2 25.2 25.6 24.0 24.7 23.4 23.5 23.3 *
70–79 23.1 22.1 22.6 21.0 20.6 21.5 20.9 20.3 20.6 *
≥ 80 18.0 17. 7 16.5 16.8 15.0 15.5 14.7 14.3 13.7 *†
Race
White 22.4 21.2 20.7 20.3 19.1 19.5 18.6 18.5 18.3 *†
Black 31.3 30.1 28.2 29.0 26.7 2 7. 3 27. 0 26.0 25.7 *†
Other 25.3 24.3 22.2 21.8 19.3 20.9 20.9 19.2 20.1 *†
Diabetes, %
Yes 25.7 24.6 23.8 23.8 22.4 22.9 22.2 21.8 21.6 *†
No 21.0 19.9 19.0 18.5 16.8 1 7. 4 16.8 16.6 16.9 *
UACR, %‡
<30 mg/g 26.3 25.4 23.4 23.3 22.3 21.6 21.7 21.3 22.1 *
30–299 mg/g 24.6 23.9 23.7 23.6 21.4 21.9 21.3 20.5 20.6 *†
≥ 300 mg/g 26.2 26.1 23.4 25.5 24.1 25.0 25.0 26.5 23.3 ns
CKD stage, %
1–2 25.2 23.7 24.6 24.4 21.7 21.5 21.1 21.0 20.8 *†
3 24.5 23.6 22.1 22.0 20.9 21.6 20.7 20.1 20.2 *†
4 18.6 17. 1 16.5 16.8 15.9 16.8 18.4 18.7 17. 6 †
5 11.8 11.2 7. 4 8.0 7. 0 11.8 9.0 8.3 11.8 †
ns, P value for linear trends in both periods, >0.05. BP indicates blood pressure; CKD, chronic kidney disease; and UACR, urine albumin-to-creatinine ratio.
*P value for linear trend between 2011 and 2014, <0.05.
†P value for linear trend between 2015 and 2019, <0.05.
‡Among those with nonmissing UACR.

Martinez et al Trends in Hypertension Control in CKD
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2542 December 2023 Hypertension. 2023;80:2533–2543. DOI: 10.1161/HYPERTENSIONAHA.123.21523
certain toxic exposures, which should extend eligibility for
VA health care to millions of Veterans with hypertension.36
This study has several limitations. First, BP measure-
ments were obtained during clinical care rather than
through standardized or ambulatory BP measurements.
We used multiple BP measurements to assess BP
control, but we acknowledge that there is an inherent
limitation of analyses utilizing electronic health records.
Second, we could not assess BP prescriptions filled at
non-VA pharmacies and whether these prescribing pat-
terns have changed over time, though some data sug-
gest that dual use of VA and non-VA pharmacies for
cardiovascular medications is infrequent.37 Third, we did
not have information on indications for BP medication
use or reasons why some patients were not receiving
treatment from our data set. Fourth, we assessed medi-
cation use based on VA pharmacy fill records, which
may not reflect medication adherence. Finally, our
cohort was comprised of US Veterans with limited rep-
resentation of women. Consequently, the results may
not necessarily generalize to women or the general
population.
In summary, the proportion of adults with CKD in
the VA who meet guideline-recommended targets for
BP control and who are prescribed antihypertensive
medication has declined over the past decade. A bet-
ter understanding of the factors driving these trends
could help improve rates of control and maximize
the benefits of treatment while minimizing potential
adverse effects.
PERSPECTIVES
In a representative sample of adults with CKD treated
in the VA, we found broad-based changes in hyperten-
sion practice patterns coinciding with a 7% age point
decline in BP control between 2011 and 2015, followed
by an uptick of 2% age points between 2015 and 2019.
The findings parallel declines in BP control observed
in the general population over the same period of time
and suggest opportunities to improve BP control in the
high-risk CKD population by focusing on the factors
that contribute to less than optimal implementation of
evidence-based therapies.
ARTICLE INFORMATION
Received May 22, 2023; accepted September 1, 2023.
Affiliations
Division of Nephrology, Department of Medicine, Stanford University School of
Medicine and VA Palo Alto Health Care System, CA (J.D.M., M.E.M.-R., A.C.P.,
M.K.T.). Geriatric Research and Education Clinical Center, VA Palo Alto Health
Care System, CA (I.-C.T., M.C.O., M.K.T.). Division of Nephrology, Department of
Medicine, Loma Linda University School of Medicine and Loma Linda VA Health
Care System, CA (E.F.). Quantitative Sciences Unit, Department of Medicine (V.C.),
Department of Pathology (V.C.), and Department of Epidemiology and Population
Health (M.C.O.), Stanford University School of Medicine, CA. Kaiser Permanente
Bernard J. Tyson School of Medicine, Pasadena, CA (J.J.S., J.A.). Department of
Medicine, Division of Nephrology and Hypertension, Kaiser Permanente Los An-
geles Medical Center, CA (J.J.S.). Research and Evaluation, Kaiser Permanente
Southern California, Pasadena, CA (J.A.).
Sources of Funding
This study was supported by R01DK128108 and K24AG073615 to M. Kurel-
la Tamura' and T32DK007357 to J.D. Martinez from the National Institutes of
Health. The views expressed are those of the authors and not necessarily those
of the Department of Veterans Affairs.
Disclosures
None.
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