Is the KDIGO Systolic Blood Pressure Target <120 mm Hg for Chronic Kidney Disease Appropriate in Routine Clinical Practice?

Abstract

Meticulous management of hypertension is important in chronic kidney disease (CKD) to reduce the risk of cardiovascular disease, mortality, and progression of CKD. The recently published Kidney Disease Improving Global Outcomes (KDIGO) guideline on blood pressure (BP) management in CKD stresses the importance of standardized BP measurement and strict control of BP. This is a useful document that will help to improve the management of hypertension in CKD globally. However, the recommendation of systolic BP target of <120 mm Hg by KDIGO is controversial. It is based on weak evidence derived mainly from a single randomized controlled trial and its CKD subgroup analysis. Here, we review the current evidence surrounding BP target in CKD. We argue that the target recommended by KDIGO is not generalizable to the majority of people with CKD. Standardized BP measurements are challenging to implement outside specialist hypertension and research clinics, and the target of <120 mm Hg BP systolic cannot be extrapolated to routine clinic BP measurements. If applied to routine BP measurement, this target will expose the multimorbid and frail CKD patients to the risk of adverse events including falls and fractures. Furthermore, it will not be achievable in the majority of CKD patients. The target recommended by KDIGO is an outlier among contemporary major international hypertension guidelines and is likely to perplex clinicians. We believe the KDIGO-recommended target systolic BP <120 mm Hg for CKD is inappropriate in the majority of CKD patients and it may even be harmful for patients managed in routine clinical practice.

Keywords: accidental falls; blood pressure; frail elderly; guideline; hypertension.

Figure 1.

The blood pressure (BP) target for chronic kidney disease patients recommended by contemporary major international guidelines. ACC indicates American College of Cardiology; ACR, urine albumin creatinine ratio; AHA, American Hypertension Association; ESC, European Society of Cardiology; ESH, European Society of Hypertension; KDIGO, Kidney Disease Improving Global Outcome; and NICE, National Institute for Health and Care Excellence.

Figure 2.

Key messages. ACCORD indicates Action to Control Cardiovascular Risk in Diabetes; ADPKD, adult polycystic kidney disease; BP, blood pressure; CKD, chronic kidney disease; GN, glomerulonephritis; KDIGO, Kidney Disease Improving Global Outcome; and SPRINT, Systolic Blood Pressure Intervention Trial.