Evaluation Of The Management Of Hypertension Among Adult Diabetic Hypertensive Outpatients With Chronic Kidney Disease At Kenyatta National Hospital

Abstract

Background: Blood pressure control is crucial for patients with comorbidities of diabetes mellitus and chronic kidney disease, as it retards the development of end-stage renal disease. Although safe and effective antihypertensive drugs are available, studies have shown that a large proportion of patients with these comorbidities do not achieve their blood pressure targets. There is a paucity of data on the adequacy of blood pressure control in adult diabetic hypertensives with chronic kidney disease in the resource-limited settings. Broad objective: To evaluate the management of hypertension in adult diabetic hypertensive outpatients with chronic kidney disease at Kenyatta National Hospital, Endocrinology and Renal Outpatient Clinics. Methodology: A tertiary hospital based cross-sectional study was done. A total of 237 patients on management for hypertension, diabetes mellitus and chronic kidney disease were randomly selected. Participants were adults aged ≥18 years and on antihypertensive treatment for at least two months. Pregnant women, psychosocially challenged, and post-renal transplant patients were excluded. Data Collection and Analysis: An interviewer-administered questionnaire was used during face to face interviews with study participants to obtain the socio-demographic data, patient-related, clinician-related and hospital-contextual factors that impact on blood pressure control. Monthly blood pressure measurements and antihypertensive drugs and dosages were abstracted from the patient medical files using a data abstraction form. Adherence to medications was assessed using a modified Morisky 8-item Medication Adherence Scale. Raw data was entered in Microsoft Excel version 2007 to create database. It was then exported to STATA software version 13 for analysis. Summary statistics were done for adequacies of blood pressure control, prevalence of use of various antihypertensives, adherence patterns and lifestyle strategies for controlling blood pressure. Associations were determined between the predictor variables such as sociodemographic data, patients’ awareness of target blood pressure, and levels of adherence, lifestyle strategies and prescription drugs versus the outcome variables, which included the level of blood pressure control. P-values ≤ 0.05 were considered statistically vii significant. Forward stepwise logistic regression analyses were done to identify independent predictors of blood pressure control. Results: The mean age of the participants was 61.8 (±12.7) with the youngest and oldest participants being 21 and 92 years old, respectively. There was an almost equal representation of both males (118, 49.8%) and females (119, 50.2%) in the study. The mean duration of hypertension, diabetes mellitus and chronic kidney disease was 10.5±8.3, 11.8±8.4 and 4.0±6.1 years, respectively. Three in every ten (30.4%) participants had ideal body weight. More than half (55.3%) of the participants were unaware of their recommended blood pressure targets. Non-adherence to prescribed medications was observed in 48.1% with the main reasons for non-adherence being forgetfulness (88.2%) and unawareness of BP goals (44.7%). As such, over two thirds (67.8%) had inadequate blood pressure control of >140/>90 mmHg. Calcium channel blockers (51.1%) was the most preferred class of antihypertensives but the most preferred combination therapy was losartan/hydrochlorothiazide (24.5%). The most prescribed single agent was carvedilol (28.7%). In addition, about a fifth of the study participants adopted reduced saturated fat and increased fiber diets and participated in physical exercises as a way of lifestyle modification to control their blood pressure. Use of nifedipine was significantly associated with adequate BP control (AOR=2.79; 95% CI 1.12-6.97; p=0.03) unlike use of atenolol (COR=0.02; 95% CI 0.05-0.87; p=0.032). Independent predictors of adequate BP control were participant’s adherence to prescribed medications (AOR=20.23; 95% CI 7.35-55.7; p<0.001) and constant reminders of blood pressure goals (AOR=4.57 95% CI 1.25-16.67; p=0.022). Conclusion: Blood pressure control among diabetic hypertensive patients with chronic kidney disease is poor and is largely due to unawareness of the blood pressure targets, non-adherence to prescribed drugs and failure to adopt lifestyle modification strategies. Recommendations: Healthcare workers should find ways of improving patients’ adherence to their antihypertensive medications and constantly remind them ideal blood pressure goals. Given that this study was cross-sectional covering a short period of time, a similar but prospective cohort study covering a large number of patients is needed to confirm our findings.