Patients with chronic kidney disease (CKD) who are not receiving dialysis should aim for a systolic blood pressure below 120 mm Hg as measured in the office using a standardized technique, according to new guideline from the Kidney Disease: Improving Global Outcomes (KDIGO) Work Group.
The guideline updates the group's 2012 recommendations and includes new evidence on the risks and benefits of blood pressure-lowering therapy among patients with CKD. It recommends a standardized target because of concerns that routine office blood pressure may entail inaccurate measurement and possible overtreatment. The Work Group stresses that the target systolic blood pressure of less than 120 mm Hg should only be applied when standardized measurements are used. The Work Group also suggests that out-of-office blood pressure measurements (ambulatory or home blood pressure monitoring) be used to complement standardized office readings for management of hypertension.
Regarding drug therapy, the guideline discusses starting renin-angiotensin system inhibitors (an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker) in people with hypertension and CKD, recommending the therapy in those without diabetes but with severely increased albuminuria and those with diabetes and moderately to severely increased albuminuria, and suggesting it in those without diabetes but with moderately increased albuminuria. The guideline recommends avoiding any combination of angiotensin-converting enzyme inhibitor, angiotensin-receptor blocker, and direct renin inhibitor therapy in patients with CKD with or without diabetes.
Regarding lifestyle recommendations, the guideline suggests a target sodium intake of less than 2 g/d in patients with hypertension and CKD and suggests that they be advised to undertake moderate-intensity physical activity for a cumulative duration of at least 150 min/wk or to a level that is compatible with their cardiovascular and physical tolerance.
A synopsis of the guideline was published June 22 by Annals of Internal Medicine. The complete clinical guideline, which includes 11 recommendations and 20 practice points, is available at the KDIGO website.
An accompanying editorial noted that the KDIGO recommendations align with other recent guidance in this area and said additional research is needed to guide clinical approaches to successfully achieving and maintaining lower blood pressure targets, enhancing patient engagement, and improving care coordination among internists and nephrologists. “Patients with CKD constitute one of several high-risk populations that receive proven cardiovascular benefit from more intensive [blood pressure] therapy,” the editorialists wrote. “Thus, the potential benefits of all clinicians implementing the KDIGO practice standards are substantial.”