2021 Kidney Disease: Improving Global Outcomes (KDIGO) Guidelines for the Management of Blood Pressure in Patients with Chronic Kidney Disease

Author: Christine Zink, MD

The Kidney Disease: Improving Global Outcomes (KDIGO) Work Group updated its guidelines for managing blood pressure in patients with chronic kidney disease (CKD) who are not receiving dialysis.1,2 This article will discuss the two significant care recommendations discussed in the guidelines, mention specific therapeutic interventions, and briefly touch on treatment gaps. Here are the highlights:

  • The KDIGO Work Group recommends a target systolic blood pressure of < 120 mm Hg in adults with chronic kidney disease who are not receiving dialysis and are not kidney transplant recipients.
  • The KDIGO Work Group recommends clinicians use proper standardized blood pressure measurement instead of routine blood pressure measurement, and they outline specific steps to achieve this goal.
  • The KDIGO Work Group bases their recommendations mainly on the SPRINT trial, which showed that when patients are managed to a target systolic blood pressure of < 120 mm Hg, they have a lower rate of cardiovascular events and death.
  • The KDIGO Work Group does not recommend specific antihypertensive treatment algorithms for patients with chronic kidney disease but does recommend using a renin-angiotensin system inhibitor since these types of medications reduce the risk of kidney failure and major cardiovascular events.
  • There is a vast treatment gap that primary care clinicians can fill to prevent significant cardiovascular events and death.

Before 2021, the KDIGO Work Group last updated their guidelines in 2012, and the recommendations for target blood pressure were the same as those recommended by the American College of Cardiology (ACC) and American Heart Association (AHA) in 2017.3 KDIGO, a global nonprofit organization that aims to improve care and outcomes of patients with kidney disease through the development and implementation of global evidence-based clinical practice guidelines,4 bases their new recommendation on evidence from the Systolic Blood Pressure Intervention Trial (SPRINT),5 systematic reviews, and other meta-analyses. The KDIGO Work Group recommends a target systolic blood pressure of < 120 mm Hg using proper standardized blood pressure measurement instead of < 130 mm Hg for patients with albuminuria and < 140 mm Hg for patients without albuminuria.1,2,6 The recommendation applies to adults with CKD who are not receiving dialysis and are not kidney transplant recipients.1,2 The updated guidelines also stress attention to proper blood pressure measurement.

Previously, the KDIGO Work Group did not have recommendations on how to measure blood pressure. In the new guidelines, they recommend standardized office blood pressure monitoring due to the high variability of blood pressure values obtained during routine office visits.1,2 Additionally, large randomized trials, like SPRINT, that study blood pressure utilize standardized, not routine, blood pressure monitoring. Casual routine blood pressure measurement often detects higher values (approximately 10 mm Hg)7 than is accurate for individual patients. This leads to overdiagnosis and overtreatment. The 2017 ACC/AHA blood pressure management guidelines also recommend standardized blood pressure measurements,3 and they include several steps adapted in the following list:2,3

    1. 1. Have the patient sit in a chair and relax for at least 5 minutes before measuring the blood pressure. The patient should also avoid stimulants and exercise at least 30 minutes before having their blood pressure taken.
    1. 2. Use a blood pressure device that has been validated and calibrated appropriately, use the correct cuff size, and position the patient’s arm resting on a desk. The type of blood pressure measuring device does not matter.
    1. 3. On the first visit, measure the blood pressure in both arms. Repeated measurements should be separated by 1 to 2 minutes. Use the arm with the higher reading for diagnosis and management, and use an average of ≥ 2 readings obtained on ≥ 2 occasions.
    1. 4. Document the blood pressure readings appropriately and give the information to the patient. Additionally, recommend out-of-office blood pressure measurements to complement standardized office measurements. However, large, randomized outcome trials that comprehensively evaluate the utilization of out-of-office blood pressure measurements have not been done.

Previously, the KDIGO Work Group recommended a target systolic blood pressure of < 130 mm Hg, but the new recommendation is < 120 mmHg.1,2 The Work Group bases the recommendation on the cardioprotective and survival benefits shown in the SPRINT trial.5 In this trial, 9,361 people from 102 sites in the United States and Puerto Rico aged 50 and older with a systolic blood pressure > 130 mm Hg and an increased risk of cardiovascular disease, but without diabetes, were divided into two groups: target systolic blood pressure < 120 mm Hg (intensive treatment group) and target systolic blood pressure < 140 mm Hg (standard treatment group). Patients in the intensive treatment group had a lower rate of cardiovascular events (reduced risk by 25%) and death (reduced risk by 27%).5,6 Unfortunately, the trial did not show renal protection with intensive blood pressure treatment. While the trial showed significant benefits, the KDIGO Work Group emphasizes that decisions regarding target blood pressure should be made individually since specific patient characteristics can change management. The SPRINT trial showed more significant adverse events in the intensive treatment group.2,5 In this group, patients were more likely to visit an emergency department for hypotension, syncope, electrolyte abnormalities, and acute kidney injury or acute renal failure.2,5

The KDIGO Work Group does not recommend specific antihypertensive treatment algorithms in patients with CKD.1,2 Studies are limited comparing different drug combinations in these patients. Therefore, therapy recommendations are based on expert opinion or extrapolated from other studies performed in the general population. The SPRINT study used a combination of a thiazide-type diuretic and/or an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor II blocker (ARB) and/or a calcium channel blocker to reach a systolic blood pressure target of < 120 mm Hg.2,5 The KDIGO Work Group recommends using a renin-angiotensin system inhibitor (RASi) at the very least in patients with CKD since multiple studies, including a meta-analysis of 64,768 patients with CKD with or without diabetes, showed that use of a RASi, like an ACE inhibitor or ARB, reduces the risk of kidney failure and major cardiovascular events compared to other therapies and placebo.2,8

After the 2021 KDIGO blood pressure guidelines were published, researchers analyzed 1,699 adults with CKD from the 2015–2018 National Health and Nutritional Examination Survey (NHANES) to determine the impacts of the new guidelines.6 They found that 69.5% of adults with CKD were eligible for blood pressure-lowering care according to the new 2021 guidelines, whereas only 49.8% of adults with CKD were eligible for blood pressure-lowering care according to the 2012 guidelines. During this analysis, the researchers also found that approximately 8.9 million patients with CKD in the United States were not taking any antihypertensive medication and would be recommended to do so based on the new guidelines. This leaves a vast treatment gap that needs to be filled to prevent significant cardiovascular events and death and to slow the speed of worsening chronic kidney disease.

Learn more about managing hypertension and how lifestyle changes can supplement medical therapy for an overall care approach. You can also view the KDIGO guidelines and executive summary. Stay up to date on all cardiovascular topics with additional cardiology cme, available at Pri-Med.com

 

References

1. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021 Mar;99(3S):S1-S87.

2. 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. Kidney Int. 2021 Mar;99(3):559-569.

3. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127–e248.

4. KDIGO. Accessed June 24, 2021. https://kdigo.org/mission/.

5. SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103–2116.

6. 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. 2021 Mar;99(3):686-695.

7. Cheng RZ, Bhalla V, Chang TI. Comparison of routine and automated office blood pressure measurement. Blood Press Monit. 2019 Aug;24(4):174-178.

8. Xie X, Liu Y, Perkovic V, et al. Renin-angiotensin system inhibitors and kidney and cardiovascular outcomes in patients with CKD: a Bayesian network meta-analysis of randomized clinical trials. Am J Kidney Dis. 2016;67:728–741.