It's that time of year again 🍂🍂🍂 The #NephJC Fall pledge drive. Plese give if you are able to support our decades long mission of #FOAMed for all. #NephSky #MedSky www.nephjc.com/news/2025/9/22/nephjc-fall-pledge-drive

1/10 Welcome to #TenPostNephJC Last #NephJC we discussed about AHA/ACC 2025 Hypertension guidelines: PREVENT, Detect, Treat Didn’t catch the pulse of this one? No worries we’ll help you pressure check the 2025 AHA Hypertension Guidelines. ❤ #AHA2025 www.ahajournals.org/doi/10.1161/...

See you all soon for the Next #NephJC chat in two weeks Signing off @jeyakumarmeyyappan.bsky.social

Thanks to all the wonderful #Nephjc mentors @brianrifkin.bsky.social @hswapnil.medsky.social @nephroseeker.medsky.social @dramiliflores.bsky.social @drpallaviprasad.bsky.social @@sayalibthakare.bsky.social

www.nejm.org/doi/full/10.... There’s some trial data on prevention of albuminuria #nephjc

It has been a great #Nephjc chat . Thanks to wonderful teammates. @salinesolut.bsky.social @msocomd.bsky.social @sejalplakhani.bsky.social @shelliefravel.bsky.social @notjustdialysis.bsky.social

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Up next! ☀️📚 We're going Sci-fi with the creation on chimeras to prevent transplant rejection 🧑‍🔬Join us 9/30/25. #NephJC Induction of immune tolerance in living related human leukocyte antigen-matched kidney transplantation: A phase 3 randomized clinical trial - PubMed

What did we miss? What else caught your attention and should be discussed? What did the guidelines get right? What did they get wrong? #NephJC

And that’s a wrap! In summary: screen carefully, stratify by risk, account for kidney health, and individualize therapy. For nephrology, the wins are undeniable: albuminuria testing is mainstream, CKD visibility is heightened, and aldosterone is on the radar. #NephJC

T5a We always need more evidence. Here’s a few areas that made list: ➡️ BP management in young adults ➡️ DBP goals ➡️ Accurate BP measurement ➡️ SDOH and BP ➡️ Genetic and epigenetic factors #NephJC

T3a 1️⃣3️⃣Terminology change – Hypertensive Urgency (BP > 180/120 without target organ damage) is now referred to as Severe HTN. No need for parenteral therapy, best to treat in the outpatient setting. 📝What’s in a name (renal, nephro, kidney)? #NephJC

T4l 1️⃣2️⃣No aggressive IV treatment for severe asymptomatic HTN - avoid acute inpatient lowering if no target-organ damage (COR III: Harm, LOE C-LD). 📝Treat the patient (situation) not the number for acute HTN during hospitalization. I have trouble convincing nocturnists of this. #NephJC

T4k 1️⃣1️⃣Renal denervation - consider only after optimized therapy, multidisciplinary review, and shared decision-making (COR I for evaluation, COR IIb for procedure, LOE B-R). 📝Don’t see this being widely used, how about you? #NephJC

T4j 🔟CKD with albuminuria - ACEi/ARB strongly recommended to delay CKD progression and reduce CVD (COR I, LOE A). 📝Still only 35-50% of eligible patients get them. How do we move the needle on this? #NephJC

T4i 9️⃣Cognitive protection🧠 - treat to SBP <130 to prevent mild cognitive impairment/dementia (COR I, LOE B-R). 📝Do you think BP control has a significant role in dementia? #NephJC

T4h 8️⃣Avoid harmful pregnancy drugs – No ACEi, ARB, renin inhibitors, atenolol, nitroprusside, MRA (COR III: Harm, LOE C-LD). 📝No arguments here! What’s your go to med for HTN in pregnancy? #NephJC

T4g 7️⃣Pregnancy thresholds updated - Treat chronic HTN in pregnancy to <140/90 and acute severe HTN ≥160/110 within 30–60 min (COR I, LOE B-R). 📝Are you routinely consulted for hypertension in pregnancy? #NephJC

T4f 6️⃣Potassium-based salt substitutes - can be useful to lower BP except in advanced CKD or hyperkalemia risk (COR IIa, LOE B-R). 📝Do you routinely warn your CKD patients against salt substitutes? #NephJC

T4e 5️⃣Primary aldosteronism screening – screen all adults with resistant HTN regardless of potassium level (COR I, LOE B-NR). Continue most antihypertensives except MRA before testing (COR I, LOE C-EO). 📝Is screening worthwhile or should we just be using MRAs earlier? #NephJC

T4d 4️⃣Stage 2 HTN therapy - start two first-line drugs, preferably single-pill combo (COR I, LOE B-R). 📝We discussed this above, barriers to use of combo pills? #NephJC

But each has benefits like a fine wine: -The uric acid lowering of losartan -The longest half life of telmisartan -The bonus migraine prophylaxis of candesartan #nephjc

T4c 3️⃣BP goal - target <130/80 mmHg for nearly all adults, including older adults if tolerated (COR I, LOE B-R). 📝One size fits all? Is this your goal for a majority of your patients? #NephJC

T4b 2️⃣Risk-based treatment threshold – Use PREVENT 10-yr CVD risk ≥7.5% to guide drug initiation at ≥130/80; if risk <7.5%, try lifestyle first for 3–6 mo, treat if still ≥130/80 (COR I, LOE B-R). 📝How effective is lifestyle modification in your practice? #NephJC

Interesting study from 2019! #NephJC 8.9% of OSA have PA. Almost 70% of PA have OSA! www.ahajournals.org/doi/10.1161/...

T4a 1️⃣BP categories unchanged - normal <120/80, elevated 120–129/<80, stage 1 130–139/80–89, stage 2 ≥140/90 (COR I, LOE B-NR). 📝You know we love to categorize things. Were you hoping for a change? #NephJC

Olmesartan’s more effective and comes in a combo w amlodipine. pmc.ncbi.nlm.nih.gov/articles/PMC... #nephjc

9:39 So ACC/AHA hasn’t updated their guidelines since 2017. Let’s break down what’s different and new! Lots to discuss #NephJC

T2p Renal denervation certainly didn’t get much love at #NephMadness this year. A significant number of patients are non-responders to RDN, without a way to predict before the procedure. Are you using/recommending RDN to your patients? #NephJC

T2o To round out the discussion on HTN management: Renal Denervation (RDN) Class 2b (weak) recommendation for renal denervation in carefully selected patients with resistant HTN. Initial studies were promising, however in the end RDN only had modest effects (equivalent to adding 1 BP med) #NephJC

T2n Studies have shown that even moderate weight loss (5-10%) can significantly lower BP. GLP-1 receptor agonists may be effective adjunctive therapy to lower BP when used for weight management in those with BMI ≥27 kg/m2 #NephJC

T2m 🎯at least <130/80 for all Encouraged to achieve a more aggressive SBP target of < 120 is recommended for those at ⬆️ risk for CVD to ⬇️ risk of CV events & mortality. SBP target of < 120 may - reasonable for those not at increased CVD risk to reduce risk of further BP elevation. #NephJC

T2l Initiation of 2 first-line agents is still recommended for Stage 2 HTN but there is a new emphasis on using single-pill combinations. One pill goes down easier than two! What’s your favorite combo pill? Not using combo pills – what’s holding you back? #NephJC www.thelancet.com/jo...#NephJC

T2k Let’s talk meds! -Thiazides, ACEi/ARBs, CCBs (long-acting dihydropyridines) remain first-line -ACEi/ARBs preferred in all patients with albuminuria ≥30 mg/g -In T2DM, ACEi/ARBs should be considered even in mild albuminuria (<30 mg/g) to delay progression of DKD #NephJC

T2h Why did the risk threshold for treatment drop from ≥10% to ≥7.5%? #NephJC

T2g What is different about PREVENT? ➡️ Includes eGFR and BMI as essential risk predictors ➡️ Includes A1C, UACR, and Zip Code as optional risk predictors ➡️ Predicts 10-yr ASCVD and HF risk individually and in combination for total CVD risk #NephJC

T2f Let’s talk about CV risk prediction with PREVENT. Pooled Cohort Equations are out, PREVENT is in! #NephJC

T2e Changed treatment thresholds: ✔️Patients with CKD or DM and BP ≥130/80 ✔️Patients with BP ≥130/80 + 10-year PREVENT-CVD risk ≥7.5% ✔️Patients with BP ≥130/80 after 3-6 months of lifestyle changes #NephJC

T2d UN-changed treatment thresholds: ✔️All patients with BP ≥140/90 ✔️Patients with CVD and BP ≥130/80 #NephJC

T2c How is the nephrology world feeling about the exclusion of patients with CKD from the promotion of K+-based salt substitutes? Is this life-saving or unnecessarily cautious? Should this be more universal (food additive- replace NaCl for KCl) necessitating more K-binders in CKD? #NephJC

T2b It’s pretty much back to the basics for lifestyle (weight loss, exercise, limiting sodium and alcohol, and eating a potassium rich diet). There are a few newcomers though: ✔️Potassium-based salt substitutes (except in CKD, think SSaSS study) ✔️Meditation ✔️Breathing control #NephJC

T2a Moving on….to management! Let’s talk about lifestyle and drugs! #NephJC

T1k Who should be screened for primary aldosteronism? Check out the recommendation below (probably many more than we are screening now): #NephJC

T1j Answer: Only 20% - 50%! Meaning at least half of patients with resistant HTN secondary to primary aldosteronism will be missed if the absence of hypokalemia discourages a provider from performing screening. #NephJC

T1i It’s quiz time! Topic – Secondary Hypertension. Question - What percent of patients with primary aldosteronism present with hypokalemia? #NephJC

Calling out the shift to automated devices! 🩺Aneroid devices are easily miscalibrated and require frequent recalibration (plus perfect hearing!) — not the best option 🤖Automated devices aren’t prone to miscalibration but need to be correctly validated — check out www.validatebp.org #nephjc

T1h Next up – Secondary HTN. The guideline provides a thorough table including 15 causes of secondary HTN with indications for additional testing and diagnostic screening tests for each. #NephJC

T1g Following a HTN diagnosis, there is more to evaluate. Here’s the list: ➡️CBC ➡️Serum electrolytes ➡️SCr ➡️Lipid profile ➡️Glucose/A1C ➡️TSH ➡️Urinalysis ➡️UACR (Hooray!) ➡️ECG Are you already doing this? Are there other parameters you routinely monitor? #NephJC