The Kidney Disease: Improving Global Outcomes (KDIGO) organization has released new 2021 clinical practice guidelines for blood pressure management in patients with chronic kidney disease (CKD) not receiving dialysis.
The current guideline, updated from the 2012 version, recommends a systolic blood pressure (SBP) target of less than 120 mm Hg in most subgroups with CKD (except kidney transplant recipients and children), largely based on evidence from SPRINT (Systolic Blood Pressure Intervention Trial). The guideline also emphasizes standardized office measurement of blood pressure (BP) for greater accuracy.
A KDIGO work group outlined key recommendations based on evidence or consensus in Kidney International. “The goal of this guideline is to provide clinicians and patients a useful resource with actionable recommendations supplemented with practice points,” they wrote. Here is a synopsis:
Employ standardized office BP measurement as used in trials because these values are more accurate than routine measurement. The guideline provides a detailed checklist. Ambulatory or home BP monitoring complements this standardized assessment.
Target less than 2 g of dietary sodium daily in patients with high BP and CKD. Also encourage moderate-intensity physical activity of at least 150 minutes per week, as tolerated.
Patients With CKD With or Without Diabetes
Treat adults with high BP and CKD to a target SBP of less than 120 mm Hg, when tolerated.
Start renin-angiotensin-system inhibitors (RASi), specifically an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), in patients with high BP, stage 1 to 4 CKD, stage 2 or 3 albuminuria (ie, an albumin to creatinine ratio of 30 mg/g or higher), whether or not they have diabetes. Avoid any combination of an ACEi, ARB, and direct renin inhibitor.
Kidney Transplant Recipients
Based on consensus only, treat adult kidney transplant recipients with high BP to a target of less than 130 mm Hg SBP and less than 80 mm Hg diastolic BP. The work group recommends a dihydropyridine calcium channel blocker (CCB) or an ARB as the first-line antihypertensive agent.
Children With CKD
In children with CKD, lower 24-hour mean arterial pressure by ambulatory BP monitoring to the 50th percentile or less of healthy children their age, sex, and height.
Potential Implications of the 2021 KDIGO BP Guideline
Kathryn E. Foti, PhD, MPH, of Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, and colleagues separately examined how the new guideline might change clinical practice using data from 9419 adults aged 20 years or older with CKD from the 2015-2018 National Health and Nutrition Examination Survey. The team estimated that the 2021 KDIGO SBP target of less than 120 mm Hg would increase the proportion of patients with CKD who are eligible for BP-lowering medications to 69.5%, compared with 55.6% and 49.8% based on the 2017 American College of Cardiology/American Heart Association guideline (target BP less than 130/80 mm Hg) and the 2012 KDIGO criteria (target BP 130/80 mm Hg or less with albuminuria or 140/90 mm Hg or less without albuminuria), respectively.
Among patients with albuminuria, 78.2% were eligible for ACEi/ARB according to the 2021 KDIGO guideline compared with 71.0% by the 2012 KDIGO guideline. Yet only 39.1% were taking an ACEi/ARB, according to Dr Foti’s team.
“Thus, our findings highlight opportunities to improve blood pressure management and reduce cardiovascular risk among adults in the United States with CKD,” the investigators wrote in Kidney International.
George Bakris, MD, director of the American Heart Association Comprehensive Hypertension Center at the University of Chicago Medicine in Chicago, Illinois, has been writing guidelines for over 20 years and thinks the KDIGO target SBP of less than 120 mm Hg is unrealistic. In an interview with Renal & Urology News, he said, the good news is the current KDIGO guideline focuses on issues relevant to people with stages 3 and 4 CKD. It is also consistent with the American Diabetes Association guideline with one major exception: the goal SBP. Fewer than two-thirds of Americans have SBP controlled to a goal of less than 140 mm Hg let alone to less than 120 mm Hg, he said. “In my opinion, the 2017 ACC/AHA guideline, while stretching some data from the SPRINT, was reasonable in their approach and settled on 130/80 mm Hg as a goal – a target that has overwhelming evidence to slow CKD and reduce CV risk,” Dr Bakris said.
Dr Bakris added that he thinks future guidelines should focus on ways to get to a goal BP. Medication adherence declines when people take 2 or more BP medications, so he would like to see a major push to develop a single BP combination pill.
Disclosure: Several KDIGO work group members declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Cheung AK, Chang TI, Cushman WC, et al. Executive summary of the KDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease. Published online February 23, 2021. Kidney Int. 99(3):559-569.
KDIGO announces publication of the 2021 blood pressure in chronic kidney disease guideline [news release]. KDIGO; February 23, 2021. doi:10.1016/j.kint.2020.10.026
Foti KE, Wang D, Chang AR, et al. Potential implications of the 2021 KDIGO blood pressure guideline for adults with chronic kidney disease in the United States. Kidney Int. 99(3):686-695. doi:10.1016/j.kint.2020.12.019