Potential implications of the 2021 KDIGO blood pressure guideline for adults with chronic kidney disease in the United States

Abstract

The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease (CKD) recommends a target systolic blood pressure under 120 mmHg based on standardized office blood pressure measurement. Here, we examined the potential implications of this new guideline for blood pressure lowering with antihypertensive medication among adults in the United States with CKD compared to the 2012 KDIGO guideline (target blood pressure 130/80 mmHg or under with albuminuria or 140/90 mmHg or under without albuminuria) and the 2017 American College of Cardiology/American Heart Association (target blood pressure under 130/80 mmHg) guideline. Additionally, we determined implications of the 2021 KDIGO guideline for angiotensin converting enzyme inhibitor (ACEi) or angiotensin II-receptor blocker (ARB) use for those with albuminuria (recommended at systolic blood pressure of 120 mmHg or over) compared to the 2012 KDIGO guideline (recommended at blood pressures over 130/80 mmHg). Data were analyzed from 1,699 adults with CKD (estimated glomerular filtration rate 15-59 ml/min/1.73m² or a urinary albumin-to-creatinine ratio of 30 mg/g or more) in the 2015-2018 National Health and Nutrition Examination Survey and averaged up to three standardized blood pressure measurements. Among adults with CKD, 69.5% were eligible for blood pressure lowering according to the 2021 KDIGO guideline, compared with 49.8% as per 2012 KDIGO or 55.6% as per 2017 American College of Cardiology/American Heart Association guidelines. Among those with albuminuria, 78.2% were eligible for ACEi/ARB use by the 2021 KDIGO guideline compared with 71.0% by the 2012 KDIGO guideline. However, only 39.1% were taking an ACEi/ARB. Thus, our findings highlight opportunities to improve blood pressure management and reduce cardiovascular risk among adults in the United States with CKD.

Keywords: albuminuria; blood pressure; chronic kidney disease; clinical practice guidelines; hypertension.

Figure 1 |

Distribution of systolic blood pressure (SBP) in US adults with chronic kidney disease (CKD) overall and by antihypertensive medication use, National Health and Nutrition Examination Survey, 2015–2018. This figure shows the distribution of SBP overall among US adults with CKD, among those not taking antihypertensive medication, and among those taking antihypertensive medication. The SBP cut points shown in the figures reflect the percentage with SBP above the thresholds used in the 2021 (<120 mm Hg) and 2012 (≤130 mm Hg with albuminuria, ≤140 mm Hg without albuminuria) Kidney Disease: Improving Global Outcomes guidelines. M, million. Abbreviations: M. million. CKD. chronic kidney disease. SBP. systolic blood pressure.