Blood Pressure Management in Chronic Kidney Disease

Guideline Recommendations

The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends a systolic blood pressure target of <120 mmHg using standardized office measurement for select patients without diabetes, advanced chronic kidney disease (CKD), or significant proteinuria 1, 2
The American College of Cardiology/American Heart Association (ACC/AHA) guideline recommends a blood pressure target of <130/80 mmHg 3, 4
The European Society of Cardiology/European Society of Hypertension (ESC/ESH) guideline recommends a systolic blood pressure target of 130-139 mmHg 3, 4
The National Institute for Health and Care Excellence (NICE) guideline recommends a blood pressure target of <140/90 mmHg for most CKD patients, with <130/80 mmHg (lowest systolic 120 mmHg) only for those with high albuminuria (ACR >70 mg/mmol) 3, 4, 5

The SPRINT trial's CKD subgroup analysis showed cardiovascular and mortality benefits but no renoprotective effect with a systolic blood pressure target of <120 mmHg 1, 2
The ACCORD trial in diabetic patients showed no overall cardiovascular benefit at the <120 mmHg target, though stroke reduction was observed 1, 2
Multiple trials comparing lower versus standard blood pressure targets in CKD show no significant reduction in total mortality, cardiovascular events, or progression to end-stage renal disease (ESRD) 6

For patients with significant proteinuria (>300 mg/day or ACR >300 mg/g), target a blood pressure of <130/80 mmHg 7, 8
For patients without significant proteinuria (ACR <300 mg/g), a target blood pressure of <140/90 mmHg is reasonable and evidence-based 3, 4
Avoid aggressive blood pressure targets (<120 mmHg systolic) in patients with diabetes, advanced CKD, or significant proteinuria 1, 2
Use standardized blood pressure measurement (automated, unattended) when possible, and do not apply the <120 mmHg target using routine office blood pressure measurement 3, 4, 5

First-line therapy for CKD with albuminuria ≥30 mg/g is an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), which reduces albuminuria beyond blood pressure effects and slows CKD progression 8
For resistant hypertension, consider adding a calcium channel blocker or thiazide-type diuretic, and for elderly patients, avoid beta-blockers and alpha-blockers unless specifically indicated 8

For hemodialysis patients (CKD stage 5D), target a pre-dialysis blood pressure of <140/90 mmHg and post-dialysis <130/80 mmHg, and emphasize salt restriction and achieving dry weight 9
The <120 mmHg KDIGO target does not apply to dialysis patients, and a U-shaped mortality curve exists, with systolic blood pressure <120 mmHg and >180 mmHg both associated with increased death risk 1, 2, 9

The KDIGO guideline recommends systolic BP <120 mmHg for most patients with CKD not receiving dialysis, but this recommendation is based exclusively on the SPRINT trial, which explicitly excluded patients with CKD stages 4 and 5, according to the Kidney Disease: Improving Global Outcomes guideline society 10, 11
The <120 mmHg target has no evidence base in patients with CKD stage 5 and represents extrapolation beyond the data, as stated by the Kidney Disease: Improving Global Outcomes guideline society 10

Target <140/90 mmHg using standardized measurement techniques, as recommended by the National Institute for Health and Care Excellence guideline society 10, 11
The National Institute for Health and Care Excellence guidelines recommend <140/90 mmHg for CKD patients, with lower targets only for those with high albuminuria, according to the National Institute for Health and Care Excellence guideline society 10
The European Society of Cardiology/European Society of Hypertension guidelines recommend systolic BP 130-139 mmHg for CKD patients, as stated by the European Society of Cardiology/European Society of Hypertension guideline society 10

CKD stage 5 patients are particularly vulnerable to falls and fractures, as well as increased hospitalization and death from overly aggressive lowering, according to the American College of Cardiology guideline society 10

If targeting lower BP goals, standardized automated office BP measurement must be used, as recommended by the American Heart Association guideline society 10, 11

Never apply the KDIGO <120 mmHg target to CKD stage 5 patients, as they were excluded from the supporting evidence, according to the Kidney Disease: Improving Global Outcomes guideline society 10, 11
The KDIGO recommendation is an outlier among international guidelines and will confuse clinicians, as stated by the American College of Cardiology guideline society 10