Blood Pressure ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/iblo20 Management of patients with hypertension and chronic kidney disease referred to Hypertension Excellence Centres among 27 countries. On behalf of the European Society of Hypertension Working Group on Hypertension and the Kidney Jean-Michel Halimi, Pantelis Sarafidis, Michel Azizi, Grzegorz Bilo, Thilo Burkard, Michael Bursztyn, Miguel Camafort, Neil Chapman, Santina Cottone, Tine de Backer, Jaap Deinum, Philippe Delmotte, Maria Dorobantu, Michalis Doumas, Rainer Dusing, Béatrice Duly-Bouhanick, Jean-Pierre Fauvel, Pierre Fesler, Zbigniew Gaciong, Eugenia Gkaliagkousi, Daniel Gordin, Guido Grassi, Charalampos Grassos, Dominique Guerrot, Justine Huart, Raffaele Izzo, Fernando Jaén Águila, Zoltán Járai, Thomas Kahan, Ilkka Kantola, Eva Kociánová, FlorianP. Limbourg, Marilucy Lopez-Sublet, Francesca Mallamaci, Athanasios Manolis, Maria Marketou, Gert Mayer, Alberto Mazza, IainM. MacIntyre, Jean-Jacques Mourad, Maria Lorenza Muiesan, Edgar Nasr, Peter Nilsson, Anna Oliveras, Olivier Ormezzano, Vitor Paixão-Dias, Ioannis Papadakis, Dimitris Papadopoulos, Sabine Perl, Jorge Polónia, Roberto Pontremoli, Giacomo Pucci, Nicolás Roberto Robles, Sébastien Rubin, Luis Miguel Ruilope, Lars Christian Rump, Sahrai Saeed, Elias Sanidas, Riccardo Sarzani, Roland Schmieder, François Silhol, Sekib Sokolovic, Marit Solbu, Miroslav Soucek, George Stergiou, Isabella Sudano, Ramzi Tabbalat, Istemihan Tengiz, Helen Triantafyllidi, Konstontinos Tsioufis, Jan Václavík, Markus van der Giet, Patricia Van der Niepen, Franco Veglio, RetoM. Venzin, Margus Viigimaa, Thomas Weber, Jiri Widimsky, Gregoire Wuerzner, Parounak Zelveian, Pantelis Zebekakis, Stephan Lueders, Alexandre Persu, Reinhold Kreutz & Liffert Vogt To cite this article: Jean-Michel Halimi, Pantelis Sarafidis, Michel Azizi, Grzegorz Bilo, Thilo Burkard, Michael Bursztyn, Miguel Camafort, Neil Chapman, Santina Cottone, Tine de Backer, Jaap Deinum, Philippe Delmotte, Maria Dorobantu, Michalis Doumas, Rainer Dusing, Béatrice Duly-Bouhanick, Jean-Pierre Fauvel, Pierre Fesler, Zbigniew Gaciong, Eugenia Gkaliagkousi, Daniel Gordin, Guido Grassi, Charalampos Grassos, Dominique Guerrot, Justine Huart, Raffaele Izzo, Fernando Jaén Águila, Zoltán Járai, Thomas Kahan, Ilkka Kantola, Eva Kociánová, FlorianP. Limbourg, Marilucy Lopez-Sublet, Francesca Mallamaci, Athanasios Manolis, Maria Marketou, Gert Mayer, Alberto Mazza, IainM. MacIntyre, Jean-Jacques Mourad, Maria Lorenza Muiesan, Edgar Nasr, Peter Nilsson, Anna Oliveras, Olivier Ormezzano, Vitor Paixão-Dias, Ioannis Papadakis, Dimitris Papadopoulos, Sabine Perl, Jorge Polónia, Roberto Pontremoli, Giacomo Pucci, Nicolás Roberto Robles, Sébastien Rubin, Luis Miguel Ruilope, Lars Christian Rump, Sahrai Saeed, Elias Sanidas, Riccardo Sarzani, Roland Schmieder, François Silhol, Sekib Sokolovic, Marit Solbu, Miroslav Soucek, George Stergiou, Isabella Sudano, Ramzi Tabbalat, Istemihan Tengiz, Helen Triantafyllidi, Konstontinos Tsioufis, Jan Václavík, Markus van der Giet, Patricia Van der Niepen, Franco Veglio, RetoM. Venzin, Margus Viigimaa, Thomas Weber, Jiri Widimsky, Gregoire Wuerzner, Parounak Zelveian, Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iblo20 Pantelis Zebekakis, Stephan Lueders, Alexandre Persu, Reinhold Kreutz & Liffert Vogt (2024) Management of patients with hypertension and chronic kidney disease referred to Hypertension Excellence Centres among 27 countries. On behalf of the European Society of Hypertension Working Group on Hypertension and the Kidney, Blood Pressure, 33:1, 2368800, DOI: 10.1080/08037051.2024.2368800 To link to this article: https://doi.org/10.1080/08037051.2024.2368800 © 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group Published online: 23 Jun 2024. Submit your article to this journal View related articles View Crossmark data ReseaRch aRticle Blood Pressure 2024, Vol. 33, No. 1, 2368800 Management of patients with hypertension and chronic kidney disease referred to Hypertension Excellence Centres among 27 countries. On behalf of the European Society of Hypertension Working Group on Hypertension and the Kidney Jean-Michel halimia, Pantelis sarafidisb, Michel azizic,d, Grzegorz Biloe,f, thilo Burkardg, Michael Bursztynh,i , Miguel camafortj, Neil chapmank , santina cottonel,m, tine de Backern, Jaap Deinumo , Philippe Delmottep , Maria Dorobantuq, Michalis Doumasr, Rainer Dusings, Béatrice Duly-Bouhanickt , Jean-Pierre Fauvelu, Pierre Feslerv,w , Zbigniew Gaciongx, eugenia Gkaliagkousiy , Daniel Gordinz , Guido Grassiaa, charalampos Grassosab, Dominique Guerrotac , Justine huartad , Raffaele izzoae , Fernando Jaén Águilaaf, Zoltán Járaiag , thomas Kahanahai , ilkka Kantolaaj , eva Kociánováak, FlorianP. limbourgal , Marilucy lopez-subletaman, Francesca Mallamaciao, athanasios Manolisap , Maria Marketouaq, Gert Mayerar , alberto Mazzaas, iainM. Macintyreat , Jean-Jacques Mouradau, Maria lorenza Muiesanav, edgar Nasraw, Peter Nilssonax , anna Oliverasay , Olivier Ormezzanoaz, Vitor Paixão-Diasba , ioannis Papadakisbb , Dimitris Papadopoulosbc, sabine Perlbd, Jorge Polóniabe, Roberto Pontremolibf , Giacomo Puccibg, Nicolás Roberto Roblesbh , sébastien Rubinbi , luis Miguel Ruilopebj, lars christian Rumpbk, sahrai saeedbl, elias sanidasbm, Riccardo sarzanibn, Roland schmiederbo , François silholbp, sekib sokolovicbq, Marit solbubr , Miroslav soucekbsbt, George stergioubu , isabella sudanobv, Ramzi tabbalatbw , istemihan tengizbx, helen triantafyllidiby, Konstontinos tsioufisbz, Jan Václavíkcacb , Markus van der Gietcc , Patricia Van der Niepencd , Franco Veglioce , RetoM. Venzincf, Margus Viigimaacg , thomas Weberch , Jiri Widimskyci, Gregoire Wuerznercj , Parounak Zelveianck , Pantelis Zebekakiscl, stephan luederscm, alexandre Persucn, Reinhold Kreutzco and liffert Vogtcp aservice de Néphrologie-Hypertension, dialyses, Transplantation rénale, Hôpital Bretonneau, Tours, France; bschool of Medicine, Aristotle university of Thessaloniki, Greece; cuniversité Paris Cité department of Cardiology, Paris, France; dAPHP, service d’Hypertension Artérielle, Hôpital européen Georges Pompidou, Paris, France; eGrzegorz Bilo, department of Cardiology, Istituto Auxologico Italiano, IrCCs, Milan, Italy; fdepartment of Medicine and surgery, university of Milano-Bicocca, Milan, Italy; gMedical outpatient department and Hypertension Clinic, university Hospital Basel, Basel, switzerland; hHypertension Clinic, Hadassah-Hebrew university Medical Center, Mount scopus, Jerusalem; iFaculty of Medicine, school of Medicine, Hadassah-Hebrew university, Jerusalem, Israel; jHypertension unit, department of Internal Medicine, Hospital Clinic, university of Barcelona, spain; kPeart-rose Clinic, Hammersmith Hospital, Imperial College Healthcare Trust, london, uK; lProMIse department, Nephrology and dialisys unit with Hypertension esH excellence Centre, university Hospital P.Giaccone, Palermo, Italy; muniversity of Palermo department of Nephrology, Palermo, Italy; ndepartment of Cardiovascular diseases, Internal Medicine, university Hospital Ghent, Ghent, Belgium; odepartment of Medicine, radboud university Medical Center, Nijmegen, the Netherlands; pHypertension unit (european society of Hypertension excellence Centre), department of Cardiology, HelorA university Hospitals, Mons, Belgium; qemergency Clinical Hospital of Bucharest department of emergency Medicineap: department of Cardiology, Bucharest, romania; r2nd Prop department of Internal Medicine, Aristotle university, Thessaloniki, Greece; sHypertoniezentrum Bonn, schwerpunktpraxis Kardiologie, Angiologie, Prävention, rehabilitation, Bonn, Germany; tservice d’HTA et Therapeutique CHu rangueil, Toulouse university, Toulouse, France; udepartment of Nephrology and Hypertension, Hôpital ed Herriot, lyon, France; vdepartment of Internal Medicine, Montpellier university Hospital, Montpellier, France; wPhyMedexp, INserM u1046, CNrs uMr 9214, university of Montpellier, Montpellier, France; xdepartment of Internal Medicine, Hypertension and Vascular diseases, Medical university of Warsaw, Warsaw, Poland; y3rd department of Internal Medicine, Papageorgiou Hospital, Aristotle university of Thessaloniki, Greece; zdepartment of Nephrology, Helsinki university Hospital and university of Helsinki, Helsinki, Finland; aaClinica Medica, university Milano Bicocca, Milan, Italy; abHypertension unit, KAT General Hospital of Attica, Greece; acservice de Néphrologie, CIC-CrB 1404, INserM enVi u1096, CHu rouen, France; addivision of Nephrology, university of liège Hospital (ulg CHu), university of liège, and Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular sciences, university of liège, liège, Belgium; aedepartment of Advanced Medical sciences, Federico II university of Naples, Italy; afVascular risk unit, Internal Medicine, Virgen de las Nieves university Hospital, Granada, spain; agsouth-Buda Center Hospital, st. Imre university Teaching Hospital, Budapest, Hungary; ahdepartment of Clinical sciences, division © 2024 The Author(s). Published by Informa uK limited, trading as Taylor & Francis Group CONTACT Jean-Michel Halimi halimi@med.univ-tours.fr service de Néphrologie-Hypertension, dialyses, Transplantation rénale, Hôpital Bretonneau, CHu Tours, 2 Boulevard Tonnellé, 37000 Tours, France supplemental data for this article can be accessed online at https://doi.org/10.1080/08037051.2024.2368800. https://doi.org/10.1080/08037051.2024.2368800 This is an open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial license (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. 2 J.-M. haliMi et al. of Cardiovascular Medicine, Karolinska Institute, stockholm, sweden; aidepartment of Cardiology, danderyd university Hospital Corp, stockholm, sweden; ajdivision of Medicine, Turku university Hospital, Turku university, Turku, Finland; akFirst department of Internal Medicine - Cardiology, Faculty of Medicine and dentistry, Palacky university olomouc and university Hospital olomouc, Czech republic; aldept. of Nephrology and Hypertension, Hypertension Center, Hannover Medical school, Hannover, Germany; amAP-HP, unité d‘hypertension artérielle, service de médecine interne, Hôpital Avicenne, Bobigny, France; anINserM uMr 942 MAsCoT, Paris 13-université Paris Nord, FCrIN INI-CrCT (Cardiovascular and renal Clinical Trialists), Bobigny, France; aoGrande ospedale Metropolitano, uoC di Nefrologia abilitata al trapianto renale, CNr epidemiologia Clinica e Fisiopatologia delle Malattie renali e dell’Ipertensione Arteriosa, reggio Calabria, Italy; apMetropolitan Hospital, Piraeus, Greece; aqHypertension outpatient Clinic, Cardiology department, Heraklion university General Hospital, Heraklion, Greece; ardepartment of Internal Medicine IV (Nephrology and Hypertension), Medical university Innsbruck Anichstrasse, Innsbruck, Austria; asInternal Medicine unit, department of Medicine, esH excellence Center unit, Italy; atCardiovascular risk Clinic, Western General Hospital, edinburgh, uK; auservice de Médecine Interne, Hôpital Franco-Britannique, levallois-Perret, France; avCentro studi diagnosi e Cura dell’Ipertensione Arteriosa e del rischio Cardiovascolare (IArC), university of Brescia and AssT spedali Civili, Italy; awst George university Medical Center Achrafieh-Beirut, lebanon; axdepartment of Clinical sciences, lund university, skane university Hospital, Malmö, sweden; ayHypertension and Vascular risk unit, department of Nephrology, Hospital del Mar, IMIM (Hospital del Mar Medical research Institute), universitat Pompeu Fabra, Barcelona, spain; azuF Hypertension et Athérothrombose, Centre européen d’excellence en Hypertension Artérielle, service de Cardiologie, CHu Michallon, Grenoble, France; baInternal Medicine department, Hospital Centre of Vila Nova de Gaia/ espinho, Portugal; bbHypertension unit, dept. of Internal Medicine, university Hospital of Heraklion, Heraklion, Greece; bcesH excellent Center Hypertension, lAIKo university Hospital, Athens, Greece; bddepartment of Cardiology, Medical university of Graz, Graz, Austria; bedepartment of Medicine CINTesIs rIse, Faculty of Medicine of Porto, Portugal; bfuniversità degli studi e IrCCs ospedale Policlinico san Martino di Genova, Italy; bgdepartment of Medicine and surgery, university of Perugia, unit of Internal Medicine - santa Maria Terni Hospital, Terni, Italy; bhBadajoz, spain; biservice de Néphrologie-transplantation-dialyse-aphérèses, CHu Bordeaux, France; bjCardiovascular risk and Hypertension, Madrid, spain; bkdepartment of Internal Medicine/Nephrology, Heinrich-Heine-university duesseldorf, duesseldorf, Germany; bldepartment of Heart disease, Haukeland university Hospital, Bergen, Norway; bmdepartment of Cardiology, lAIKo General Hospital, Athens, Greece; bnuniversità Politecnica delle Marche and IrCCs-INrCA department of Clinical and Molecular sciences, Ancona, Italy; bodepartment of Nephrology, Hypertension university Hospital erlangen, Friedrich Alexander university erlangen/Nürnberg, Germany; bpservice de Médecine Vasculaire et Hypertension Artérielle, Centre de compétence régional des maladies artérielles rares, Centre d’excellence européen en Hypertension Artérielle 264, rue saint Pierre, CHu Timone, Marseille, France; bqPlava Medical Group, sarajevo, Bosnia and Herzegovina; bruniversity Hospital of North Norway department of Nephrology cb: department of Internal Medicine and Cardiology, Tromsø, Norway; bs2nd department of Internal Medicine, st. Anne’s university Hospital, Brno, Czech republic; btFakulty of Medicine, Masaryk university Brno, Czech republic; buschool of Medicine, Third department of Medicine, sotiria Hospital, Hypertension Center sTrIde-7, National and Kapodistrian university of Athens, Athens, Greece; bvuniversity Hospital Zurich university Heart Center, Cardiology and university of Zurich, Zurich, switzerland; bwdepartment of Cardiology, Abdali Hospital, Amman, Jordan; bxdivision of Cardiology, Izmir Medicana International Hospital, Yenisehir, Turkey; by2nd department of Cardiology, Medical school, university of Athens, ATTIKoN Hospital, Athens, Greece; bz1st department of Cardiology, National and Kapodistrian university of Athens, Hippocratio Hospital, Greece; cadepartment of Internal Medicine and Cardiology, university Hospital ostrava, Czech republic; cbFaculty of Medicine, university of ostrava, Czech republic; ccMedinische Klinik für Nephrologie und internistische Intensivtherapie, Charité - universitätsmedizin Berlin, Berlin, Germany; cddepartement of Nephrology & Hypertension, universitair Ziekenhuis Brussel department of Nephrology and Hypertension, VuB, Belgium; cedepartment of Medical sciences, university of Turin, Italy; cfdepartment of Nephrology, Cantonal Hospital Graubuenden, Chur, switzerland; cgCentre of Cardiology, North estonia Medical Centre, Tallinn university of Technology, Tallinn, estonia; chCardiology department, Klinikum Wels-Grieskirchen, Wels, Austria; ciIIIrd Internal department, Centre for Hypertension, General Faculty Hospital, Charles university, Prague, Czech republic; cjservice de néphrologie et d’hypertension, lausanne university Hospital and university of lausanne, lausanne, switzerland; ckCenter of Preventive Cardiology, Armenia Parounak Zelveian, Hospital N2 CJsC, Yerevan, Armenia; clHypertension unit of the First department of Medicine, Aristotle university of Thessaloniki, AHePA Hospital, Thessaloniki, Greece; cmst. Josefs Hospital, Cloppenburg, Germany; cndepartment of Cardiovascular diseases, division of Cardiology, Cliniques universitaires saint-luc and Pole of Cardiovascular research, Institut de recherche expérimentale et Clinique, université Catholique de louvain, Brussels, Belgium; coInstitute of Clinical Pharmacology and Toxicology, Charité – universitätsmedizin Berlin, Corporate Member of Freie universität Berlin and Humboldt-universität zu Berlin, Berlin, Germany; cpdepartment of Internal Medicine, section of Nephrology, Amsterdam university Medical Center, Amsterdam Cardiovascular sciences, university of Amsterdam, Amsterdam, the Netherlands ABSTRACT Objective Real-life management of patients with hypertension and chronic kidney disease (cKD) among european society of hypertension excellence centres (esh-ecs) is unclear : we aimed to investigate it. Methods a survey was conducted in 2023. the questionnaire contained 64 questions asking esh-ecs representatives to estimate how patients with cKD are managed. Results Overall, 88 esh-ecs representatives from 27 countries participated. according to the responders, renin-angiotensin system (Ras) blockers, calcium-channel blockers and thiazides were often added when these medications were lacking in cKD patients, but physicians were more prone to initiate Ras blockers (90% [interquartile range: 70–95%]) than MRa (20% [10–30%]), sGlt2i (30% [20– 50%]) or (GlP1-Ra (10% [5–15%]). Despite treatment optimisation, 30% of responders indicated that hypertension remained uncontrolled (30% (15–40%) vs 18% [10%–25%]) in cKD and cKD patients, respectively). hyperkalemia was the most frequent barrier to initiate Ras blockers, and dosage reduction was considered in 45% of responders when kalaemia was 5.5–5.9 mmol/l. conclusions Ras blockers are initiated in most esh-ecs in cKD patients, but MRa and sGlt2i initiations are less frequent. hyperkalemia was the main barrier for initiation or adequate dosing of Ras blockade, and Ras blockers’ dosage reduction was the usual management. ARTICLE HISTORY Received 8 May 2024 Revised 31 May 2024 accepted 5 June 2024 KEYWORDS chronic kidney disease; hypertension; management; Ras blockers; hyperkalaemia; sGlt2 inhibitors; mineralocorticoid receptor antagonists; guidelines BlOOD PRessuRe 3 PLAIN LANGUAGE SUMMARY What is the context? hypertension is a strong independent risk factor for development of chronic kidney disease (cKD) and progression of cKD to esKD. improved adherence to the guidelines in the treatment of cKD is believed to provide further reduction of cardiorenal events. european society of hypertension excellence centres (esh-ecs) have been developed in europe to provide excellency regarding management of patients with hypertension and implement guidelines. Numerous deficits regarding general practitioner cKD screening, use of nephroprotective drugs and referral to nephrologists prior to referral to esh-ecs have been reported. in contrast, real-life management of these patients among esh-ecs is unknown. Before implementation of strategies to improve guideline adherence in europe, we aimed to investigate how patients with cKD are managed among the esh-ecs. What is the study about? in this study, a survey was conducted in 2023 by the esh to assess management of cKD patients referred to esh-ecs. the questionnaire contained 64 questions asking esh-ecs representatives to estimate how patients with cKD are managed among their centres. What are the results? Raas blockers are initiated in 90% of esh-ecs in cKD patients, but the initiation of MRa and sGlt2i is less frequently done. hyperkalemia is the main barrier for initiation or adequate dosing of Raas blockade, and its most reported management was Raas blockers dosage reduction. these findings will be crucial to implement strategies in order to improve management of patients with cKD and guideline adherence among esh-ecs. Introduction Hypertension is a strong independent risk factor for development of chronic kidney disease (CKD) and progression of CKD to end-stage kidney disease (ESKD) [1]. According to guidelines, the diagnosis of CKD in hypertensive patients is based on evaluation of kidney function (estimated glomerular filtration rate (eGFR)) and the use of the urinary albumin/cre- atinine ratio (UACR) [1,2]. These clinical practice guidelines have been widely disseminated for many years and recently re-emphasised [1,3,4]. We recently conducted a survey among European Society of Hypertension excellence centres (ESH-ECs) among 27 countries. This survey indicated numerous deficits regarding CKD screening, use of nephroprotective drugs and it appeared that referral to nephrologists from general practitioners before referral to ESH- ECs was infrequent. However, results varied widely across countries. These deficits were mostly related to low rates of UACR screening and low use of renin-angiotensin system blockers (RASb), glucose co-transporter 2 inhibitors (SGLT2i) and mineralocor- ticoid receptor antagonists (MRA) [5]. However, how these CKD patients are managed in ESH-ECS has not been reported so far and remains unknown. Wide dissemination of current guidelines is expected in ESH-ECs but whether these guidelines are imple- mented is also unknown. Physicians in these ESH-ECs are recognised experts in hypertension exploration and management. However, real-life management of patients with hypertension and CKD in these ESH-ECs is unclear. Several issues in patients with hypertension and CKD, including use of antihypertensive medica- tions (especially RASb) when they are lacking, initia- tion and barriers to use medications such as RASb, MRA, SGLT2i and Glucagon-like peptide-1 receptor agonists (GLP1-RA) [3], the prevalence of uncon- trolled hypertension [6], and management of non- severe hyperkalaemia [7]. Before implementation of strategies to improve guideline adherence in Europe, it is crucial to investigate how patients with CKD and hypertension are managed among the ESH-ECs. In the present study, we assessed how CKD patients are managed among the ESH-ECs and whether ESH-ECs management of these patients markedly dif- fered across centres. Methods Design of the survey and participants A survey was conducted in 2023 among the ESH-ECS network. Briefly, the questionnaire was drafted by the chair (JMH) and vice-chair (LV) of the Hypertension- Kidney Working Group (HT-Kidney-WG) in February 2023, thereafter validated by 3 other members of the ESH (AP, RK, PS), made accessible online and sent by emails between March and June 2023 to all mem- bers of the ESH-ECS network. Data-management and analyses were conducted between July and September 2023. Contents of the survey The content of the questionnaire has been published (Halimi et  al. J Hypertens). Briefly, the questionnaire included ESH-ECS and patient characteristics, includ- ing renal diagnosis, use of RASb, SGLT2i and MRA in CKD patients prior to ESH-ECS referral and the specific management of CKD patients in the ESH-ECS (Supplemental Table 1). 4 J.-M. haliMi et al. Primary CKD was defined as CKD due to primary renal diseases such as glomerulonephritis, polycystic kidney disease, lupus erythematous (i.e. lupus nephri- tis) not related to cardiovascular and metabolic disor- ders. Secondary CKD was defined as CKD associated with hypertension, vascular disease or diabetes mellitus. Variations among 27 countries from Europe and in the Middle East regarding management of CKD in the ESH-ECS In this analysis, we assessed whether and to what extent to which RASb, SGLT2i, or MRA were added in CKD patients when these drugs were lacking, and whether a significant variability in management of CKD patients was present in ESH-ECS in Europe. Statistical analyses Descriptive data are presented as median (IQR, Interquartile Range) for quantitative variables and counts and percentages for categorical variables. Comparisons of parameters among centres were per- formed using Wilcoxon test, chi2 test or Fisher’s exact test as appropriate. Statistical analysis was performed using SAS (SAS 7.1 SAS Institute Inc., SAS Campus Drive, Cary, NC, USA). Results Survey responders among ESH-ECS across European and Middle East countries Overall, 88 responses were provided from 27 coun- tries (24 from Europe and 3 from the Middle East) (Supplemental Table 2). The survey was fully com- pleted in 66/88 of cases (75.0%). Most of the patients seen in ESH-ECS belonging to the <50 (median: 25% [IQR: 20–30%]) and 50–69-year (40% [30–50%]) age groups. Type 2 diabetes mellitus was present in 33% (25–50%) of cases. Known cardiovascular disease was present in 25% (15–35%) (heart failure: 20% (10– 30%)) of patients. Secondary kidney diseases (30% [20–45%]) were more frequent than primary kidney diseases (10% [5–15%]) Management of CKD patients in ESH-ECS Overall, according to the responses to this question- naire, RASb, calcium-channel blockers (CCB) and thi- azides were often added when these medications were missing (Table 1), and this was especially true for CKD patients (Table 1). Physicians in these ESH- ECs were more prone to initiate ACEI or ARB (90% [70–95%]) than MRA (20% [10–30%]), SGLT2i (30% [20–50%]) or (GLP1-RA (10% [5–15%]) when these medications were missing (Table 2). After optimisation of treatments, 30% of respond- ers indicated that uncontrolled hypertension was still present in 30% (15–40%) patients with CKD (vs 18% [10%–25%] in all patients) (Table 2). Interestingly, there was no significant differences in the management of CKD patients among ESH-ECS responders (Tables 1 and 2). Barriers to RASb optimisation in CKD patients Physicians were asked to classify potential barriers to RASb use from 1 (the most important or most frequent one) to 4 (the least frequent or least import- ant one) among cough, hyperkalaemia, acute kidney injury (AKI) and low eGFR (usually < 30 ml/ min/1.73m2). Hyperkalemia (32.3%) was usually con- sidered the most frequent one, followed by cough (25%), AKI (15.4%) and low eGFR (12.3%) (Table 3, Figure 1). Table 1. Initial treatments among all patients and patients with CKd in esH-eCs.   n Median IQr Min Max p Value Among all patients             Angiotensin-converting enzyme inhibitors (mono/combination) (%) 67 40 30–60 5 90 .6066 Angiotensin-receptor blockers (mono/combination) (%) 66 50 35–70 10 95 .4501 Calcium-channel blockers (%) 67 60 50–80 10 100 .0600 Thiazides (%) 67 50 30–70 15 100 .3372 loop diuretics (%) 66 15 10–25 5 80 .4488 Beta-blockers (%) 67 25 15–40 5 80 .6516               Among CKd patients           Angiotensin-converting enzyme inhibitors (mono/combination) (%) 66 40 30–60 10 95 .2877 Angiotensin-receptor blockers (mono/combination) (%) 66 43 30–60 10 100 .6526 Calcium-channel blockers (%) 65 70 50–80 15 100 .6932 Thiazides (%) 64 42.5 20–60 5 100 .1973 loop diuretics (%) 65 30 20–50 5 80 .1829 Beta-blockers (%) 65 30 20–40 5 90 .7990 Notes: p Values: comparisons of treatments among all esH-eCs. esH-eCs: european society of Hypertension excellent Centres. BlOOD PRessuRe 5 Management of non-severe hyperkalaemia Among patients treated with RASb, 45% of respond- ers indicated that dosage reduction would be consid- ered when kalaemia ranged between 5.5 to 5.9 mmol/L; 30% indicated that they would rather consider the addition of potassium binders, and 10% would not modify treatments. Of note, there were no significant differences among ESH-ECs responders (Table 4). Potential differences between ESH-EC with versus centres without a nephrologist We did not find any significant difference regarding any of the studied parameters (initiation of medica- tions: SGLT2i (p = .4176), MRA (p = .5491), GLP1-RA (p = .1152); barriers to the use of RAS blockers: cough (p = .1251), eGFR deemed too low (p = .8651), acute kidney injury (p = .5830), hyperkalaemia (p = .0649); management of mild to moderate hyperkalaemia: low- ering dose of RASb (p = .6497), use of lowering potas- sium drugs (p = .4081), no change in the dose of RASb (p = .1881); uncontrolled hypertension among CKD patients (p = .7933)). Discussion The results of the present study indicate that ACEI/ ARB, MRA and SGLT2i were initiated upon referral to ESH-ECS in 90%, 20% and 30%, respectively, according to the responders of this survey. Despite optimisation of treatments, uncontrolled hypertension was still present in 30% in CKD patients compared to 18% in other hypertensive patients without CKD. Hyperkalemia was the main identified barrier to RAAS blockade. For half of responders, management of moderate hyperkalaemia was reduction of RAAS dosage rather than addition of potassium binders or no treatment modification. No significant difference was noted regarding management of CKD patients among the ESH-ECS. The results of the present study indicate that the initiation of ACEI/ARB was performed in 90% of patients with CKD, according to responders of this survey. The initiation of RAAS blockers by 90% of responders is justified by the results of several clinical trials among diabetic and nondiabetic patients [8–10] and recent European guidelines [1]. RAAS blockers have been shown to reduce proteinuria, the rate of eGFR decline, and the risk of renal failure, especially in protein uric patients [1]. These results are not sur- prising and correspond to a standard of care for most patients with CKD. It is reassuring that guidelines regarding initiation of ACEI/ARB are respected. In marked contrast, the initiation of MRA was performed in only 30% of patients with CKD with eGFR > 30 ml/min. According to these recent guide- lines, the use of MRA was advocated in patients with CKD, when blood pressure (BP) was uncontrolled despite the use of 3 anti-hypertensive medications (ACEI or ARB, CCB and diuretics) at least when eGFR was > 30 ml/min/1.73m2 [1]. Only 20% of responders indicated that they consider MRA use in patients with CKD. It is presently unclear whether MRA would be a steroidal MRA such as spironolac- tone or one such as the non-steroidal MRA Table 2. Treatment of CKd patients and proportion of patient with uncontrolled hypertension. Proportion of CKd patients in whom specific treatments are initiated n Median IQr Min Max p Value   Proportion of CKd patients in whom ACeI/ArB are initiated 66 90 70–95 5 100 .5293   Proportion of CKd patients in whom MrA are initiated 66 20 10–30 5 50 .0686   Proportion of CKd patients in whom sGlT21 are initiated 65 30 20–50 5 100 .1397   Proportion of CKd patients in whom GlP1-rA are initiated 63 10 5–15 5 35 .0966               Proportion of patients with uncontrolled hypertension after treatment optimization               CKd patients (%) 63 30 15–40 5 90 .4235   All patients (%) 62 18 10–25 5 80 .3051 Note: CKd: chronic kidney disease; MrA: mineracorticoid receptor antagonist; sGlT2i: sodium-glucose transporter inhibitors; GlP1-rA: glucagon-like pep- tide 1 receptor-agonist; IQr: interquartile range. Table 3. barriers to rAs blockers in CKd patients. Barriers to rAs blockade optimization (1 to 4) in CKd patients   1 2 3 4a p Value Cough (%) 64 25 12.5 12.5 50 .9766 Hyperkalemia (%) 65 32.3 29.2 27.7 10.8 Acute kidney injury after rAs blockade challenge (%) 65 15.4 24.6 50.8 9.2 eGFr considered too low (i.e. usually <30 ml/min) (%) 65 12.3 35.4 26.2 26.2 Note: rAs: renin angiotensin system; eGFr: estimated glomerular filtration rate. a1 (the most important/frequent) to 4 (least frequent/least important). 6 J.-M. haliMi et al. finerenone. A recent meta-analysis of randomised clinical trials showed that spironolactone was supe- rior in lowering BP than other antihypertensive med- ications, although the BP difference was modest and very few studies were available for analysis [11]. Finerenone reduces BP and has significant beneficial effect vs placebo on the risk of end-stage kidney dis- ease and heart failure among patients with CKD and type 2 diabetes mellitus [12–15]. One of the main barriers for the use of MRA is the risk or at least the fear of hyperkalaemia. Real-world data show that hyperkalaemia is associated with increased mortality [16]. In our study, the fear of hyperkalaemia was also the main barrier for RAAS blockers. Mild to moder- ate hyperkalaemia (<6.0 mmol/L) can be managed using potassium binders, lowering RAAS blockers dosage, adding thiazide or loop diuretics in patients with uncontrolled hypertension, or one can opt to monitor closely potassium levels. In our study, lower- ing RAAS blockers dosage was more frequently cho- sen than the other options [17,18]. In the literature, it was reported that the most frequent reason for dose reduction or discontinuation of RAAS blockers in CKD patients was hyperkalaemia; however, it was also observed that dose reduction or discontinuation of RAAS blockers could result in increased cardio- vascular morbidity [19–23]. Our findings that the initiation of MRA was infrequently performed in CKD patients and the discontinuation or dose reduc- tion of RAAS blockers was usually considered, even among ESH-ECs, are in marked contrast with a recent consensus statement [24] and the European guidelines [1]. In the ESH guidelines, it was stated that « a potassium binder can be used to maintain normal or near normal serum potassium levels (<5.5 mmol/L) in order to allow optimal treatment with a RAS-blocker or a MRA to continue » [1]. A potential reason could be the existence of a certain time lag before new recommendations are well applied in routine clinical practice. Despite optimisation of treatments, uncontrolled hypertension was still present in 30% in CKD patients. In our study, uncontrolled hypertension was con- firmed by ambulatory or home BP measurements. Similar numbers were observed in other studies [6,25]. The consequences have been widely identified, including heart failure, progression of renal disease, hypertensive encephalopathy and malignant hyperten- sion [26–28]. Moreover and in accordance with the literature, uncontrolled hypertension was more Figure 1. Barriers to rAs blockers’ optimisation according to responders (%) (among hyperkalemia, cough, AKI and low GFr). Table 4. Management of non-severe hyperkalemia. Non-severe hyperkalemia management n Median IQr Min Max p Value Among patients with hyperkalemia (5.5 to 5.9 mmol/l) treated with rAs blockers               Proportion of K + lowering treatments considered (%) 65 30 10–80 5 100 .5028   Proportion of dosage reduction of rAs blockers (%) 67 45 20–80 5 100 .7954   Proportion of patients without treatment modification 56 10 5−37.5 5 95 .2477 Notes: p Values for differences among european society of Hypertension-excellent Centres; rAs: renin angiotensin system; IQr: interquartile range. BlOOD PRessuRe 7 frequent in CKD patients than in patients without CKD in the present study [6,29]. Surprisingly, only 30% of the responders indicated that they add SGLT2i in patients with CKD. In marked contrast, recent guidelines recommend adding SGLT2i in diabetic and non-diabetic patients with CKD [1,30–33]. SGLT2i demonstrated significant ben- eficial effects on cardiovascular morbidity and mortal- ity in addition to large reductions in kidney major events [34–36]. These guidelines are recent but have been largely disseminated [37,38]. Barriers to the pre- scription of SGLT2i have not been assessed in the present study. However, the low use of SGLT2i is cer- tainly influenced by restrictive health care and reim- bursement policies in some countries, that may result in low prescription rates. It is probably true in other countries: it was noted that ‘there remain serious challenges to implementation, particularly in the United States where inequities in insurance coverage and high costs limit their use, particularly in vulner- able populations, ultimately widening health care dis- parities’ [39]. In addition, the low reported rate of single RAAS blockade use might have influenced SGLT2i prescription by the ESH-ECS physicians, because RAAS blockade is considered to represent the first line of cardiorenal therapy. It is also important to consider that SGLT2i as well as GLP1-RA are rela- tively new treatments for nephrologists and hyperten- sion specialists. Further studies to examine the trends in prescription rates in the future are warranted for the aforementioned agents. Overall, no significant differences were noted in the management of CKD patients among the ESH-ECS but it does mean that difference do not exist, as the number of centres per country was small and heterogenous. In contrast, using the same survey, we observed a high degree of heterogeneity regarding screening and management of hypertensive patients with CKD in the countries of Europe and the Middle East before being referred to the ESH-ECs in our previous study (Halimi JM, in press, J Hypertension). Based on the present results and previous one in ESH-ECs (Halimi JM, in press, J Hypertension), a clearer view of the unmet needs regarding manage- ment of hypertensive patients before referral to ESH-ECS and within the ESH-ECS (Table 5): these unmet needs are clearly different: at the GP level, the 3 main unmet needs are: yearly screening (UACR and serum creatinine), increased use or maintenance of ACEI/ARB and introduction of SGLT2i, and rein- troduction of these medications if they have been stopped after an acute event in patients with CKD; at the ESH-ECS levels, implementation of BP goals according to current guidelines, addition of SGLT2i and MRA according to local regulations and main- tain ACEI/ARB and MRA in patients with mild to moderate hyperkalaemia (Table 5). The strength of this survey derives from the large number of ESH-ECS and countries involved in this survey. This is the first survey investigating the man- agement of CKD patients referred to Hypertension Excellence centres in Europe. This study has limitations. Many Excellent centres across Europe responded to this survey, and actually many more than most surveys in Excellence centres [40,41]; however, not all of them responded, and the reasons of non-response are unclear. Within the limits of this survey, it was not possible to obtain real data from patients followed in the same centres. The diag- nosis of comorbidities was not rigorously assessed in this survey: it is only assumed that these conditions are defined using the best available guidelines as usu- ally 80% of the responders in such surveys have a professional experience of 10 years or more. Participants willingly participated and therefore a selection bias is possible. It also explains the various number of centres within and across countries. In the present survey, the BP measurement methods and the proportion of ESH-ECs using ambulatory BP monitoring and home blood pressure were not explored. In conclusion, the results of our survey indicate that RAAS blockers are initiated in 90% of centres in CKD patients but the initiation of other nephroprotective agents such as MRA and SGLT2i is less frequently done, according to responders. Despite optimisation of treat- ments, uncontrolled hypertension was still present in 30% in CKD patients. The most frequent barrier to RAAS blockade was hyperkalaemia, and for half of responders, management of moderate hyperkalaemia was RAAS blockers dosage reduction rather than addition of potassium binders or no treatment modification, in marked contrast to current guidelines. No significant Table 5. Major unmet needs at the GP and esH-eCs levels to improve management of patients with CKd. Adequate management in hypertensive patients with CKd GP level esH-eCs level uACr / eGFr yearly measurement Implementation of BP goal (pharmacological and non pharmacological aspects) Add or maintain rAs blockers, introduce sGlT2i Add sGlT2i and MrA according to local regulations Increase use of rAs blockers, reintroduce them if stopped do not reduce or withdraw rAs blockers/MrA in mild to moderate hyperkalemia (5.5–5.9 mmol/l) Note: uACr: urinary albumin creatinine ratio; rAs blockers: renin angio- tensin system blockers; sGlT2i: sodium-glucose transporter inhibitors; MrA: mineralocorticoid receptor antagonists; GP: general practitioners; esH-eCs: european society of Hypertension excellent Centres. 8 J.-M. haliMi et al. difference was noted regarding management of CKD patients among the ESH-ECs. Author contributions Prof Jean-Michel Halimi had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Prof Reinhold Kreutz, Prof Jean-Michel Halimi, Prof Liffert Vogt, Alexandre Persu. Acquisition, analysis, or interpretation of data: Prof Reinhold Kreutz, Prof Jean-Michel Halimi, Prof Liffert Vogt, Prof Pantelis Sarafidis, Alexandre Persu. Drafting of the manuscript: Prof Jean-Michel Halimi. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Prof Jean-Michel Halimi. Disclosure statement The authors report no conflicts of interest relating directly to the contents of this article. Jean-Michel Halimi reported fees for advisory boards or lectures from Alexion, Astra Zeneca, Bayer, Boehringer Ingelheim France, Servier, Vifor Fresenius Pharma. Daniel Gordin reported lecture or advisory board hono- raria from Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, GE Healthcare, Fresenius, Novo Nordisk. He was supported by Liv och Hälsa Society, Medical Society of Finland (Finska Läkaresällskapet), Sigrid Juselius Foundation, Helsinki University Hospital, University of Helsinki, Wilhelm and Else Stockmann Foundation, Minerva Foundation Institute for Medical Research Clinician Scientist, and Academy of Finland. Markus van der Giet reported lecture fee from Bayer, Astra Zeneca, Medtronic, Omron, Vifor, Berlin-Chemie, Novartis, Apontis, Streamed-Up, Akademie der Hochdruckliga; Advisory boards for Bayer, GSK, Apontis. George Stergiou reported lecture and consulting fees from Astra Zeneca, Menarini, Sanofi-Aventis, Servier, Viatris. Ilkka Kantola received lecture fees from Bayer and Boehringer-Ingelheim Marit Solbu have received lecture honoraria from AstraZeneca and Boehringer-Ingelheim. Funding The Survey was conducted through an unrestricted educational grant from AstraZeneca. The sponsor had no involvement in the analyses and the development of the manuscript. ORCID Michael Bursztyn http://orcid.org/0000-0001-7239-0501 Neil Chapman http://orcid.org/0000-0003-1307-9275 Jaap Deinum http://orcid.org/0000-0003-2465-1986 Philippe Delmotte http://orcid.org/0000-0002-8789-8225 Béatrice Duly-Bouhanick http://orcid.org/0000-0001- 5162-8779 Pierre Fesler http://orcid.org/0000-0002-7831-6545 Eugenia Gkaliagkousi http://orcid.org/0000-0002-6324- 2475 Daniel Gordin http://orcid.org/0000-0003-1494-8292 Dominique Guerrot http://orcid.org/0000-0002-5953- 5785 Justine Huart http://orcid.org/0000-0002-5455-8769 Raffaele Izzo http://orcid.org/0000-0002-0308-2836 Zoltán Járai http://orcid.org/0000-0003-0650-9361 Thomas Kahan http://orcid.org/0000-0001-9909-4956 Ilkka Kantola http://orcid.org/0000-0002-6228-522X FlorianP. Limbourg http://orcid.org/0000-0002-8313- 7226 Athanasios Manolis http://orcid.org/0000-0002-4273- 4489 Gert Mayer http://orcid.org/0000-0003-4605-1789 IainM. MacIntyre http://orcid.org/0000-0003-4420-3822 Peter Nilsson http://orcid.org/0000-0002-5652-8459 Anna Oliveras http://orcid.org/0000-0002-5503-545X Vitor Paixão-Dias http://orcid.org/0000-0002-6521-2675 Ioannis Papadakis http://orcid.org/0000-0002-9121-296X Roberto Pontremoli http://orcid.org/0000-0003-1238-872X Nicolás Roberto Robles http://orcid.org/0000-0002-3999- 3607 Sébastien Rubin http://orcid.org/0000-0002-1246-0712 Roland Schmieder http://orcid.org/0000-0003-2356-5883 Marit Solbu http://orcid.org/0000-0002-4331-7548 George Stergiou http://orcid.org/0000-0002-6132-0038 Ramzi Tabbalat http://orcid.org/0000-0003-2628-9618 Jan Václavík http://orcid.org/0000-0001-7847-0967 Markus van der Giet http://orcid.org/0000-0003-3590- 5451 Patricia Van der Niepen http://orcid.org/0000-0002-6401-1580 Franco Veglio http://orcid.org/0000-0002-6654-6247 Margus Viigimaa http://orcid.org/0000-0001-5575-5978 Thomas Weber http://orcid.org/0000-0003-0617-0417 Gregoire Wuerzner http://orcid.org/0000-0002-6424- 7630 Parounak Zelveian http://orcid.org/0000-0002-6513-6772 References [1] Mancia G, Kreutz R, Brunstrom M, et  al. 2023 ESH guidelines for the management of arterial hyperten- sion The Task Force for the management of arterial hypertension of the European Society of Hypertension Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). 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