B-CRF: Cardiovascular complications
E- 01: Hypertension with renal diseases
Blood Pressure Targets in CKD
Raymond R. Townsend
Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Journal : Advances in Chronic Kidney Diseases
Year :2015 / Month : March
Volume : 22
Pages : 96 - 101
DOI: http://dx.doi.org/10.1053/j.ackd.2014.08.001
ABSTRACT
With the release of the 2014 Guidelines for the Management of Hypertension in Adults, a
significant amount of discussion has ensued around both the 9 major recommendations
promulgated by the Panel and the nature of the evidence base used to formulate those
recommendations. In this article, the author will review the data used to support the 2
recommendations made by the Panel that specifically addressed treatment goals
(Recommendation 4) and desirable agents to use (Recommendation 8) in hypertensive patients
with CKD. Most published recommendations are actually similar, and there is a general
consensus that the blood pressure goal should be at least less than 140/90 mm Hg in CKD;
some recommend a target of less than 130/80 mm Hg in patients with CKD who have significant
proteinuria. This article represents the view of the author and should not be construed as Panel
endorsement.
Key Words: Blood pressure target, Chronic kidney disease, Guideline
COMMENTS
The pre-eminence of BP as the single most important risk factor for premature death and
disability in the world warrants careful consideration of recommendations for target levels.
Because drug therapies are not without risk, the most convincing strategy involved in the
recommendation of a BP target is the demonstration of the point at which treatment benefits
outweigh the risks with respect to important health outcomes.
In this article, the evidence base for BP targets in CKD and drug treatment and the various
recommendations for BP targets are compared in the hope of providing more light than heat in
this still somewhat contentious area of clinical medicine.
Comparison of Guideline Recommendations for CKD BP Targets (Table 1 of the article)
Guideline (y)
CKD
Target
BP
JAMA (2014)
No specific recommendations if
No
distinction
for
older
than
70 y.
<140/90 mm proteinuria; if diabetes
Recommendation 8 endorses
Hg
present, no change in
using an ACEI or an ARB in the
target BP
treatment
CHEP (2014)
Specifies
nondiabetic
Supports using ACEI (or ARB if
<140/90 mm CKD; if diabetes present
ACEI intolerant) particularly
Hg
target BP is <130/80 mm
when proteinuria present
Hg
ESC/ESH (2013)
Suggested <130 mm Hg
Supports using ACEI or ARB,
<140/90 mm SBP
when
overt
particularly when proteinuria
Hg
proteinuria present with
present
eGFR monitoring
KDIGO (2012)
<140/90 mm In the absence
Hg
proteinuria
KDIGO (2012)19
<130/80 mm
With proteinuria
Hg
ISHIB (2010)20
Target BP shown is
Supports using ACEI or ARB,
<130/80 mm recommended for black
particularly when proteinuria
Hg
patients with any target
present
organ damage
Notes
Other Comments
of
—
—
The NICE guidelines for
NICE
(2008) <140/90 mm CKD present a range of
—
www.nice.org.uk/cg73 Hg
120-139 mm Hg systolic
as suggested target BP
Abbreviations: ACEI, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor
blocker; eGFR, estimated glomerular filtration rate; NICE, National Institute for Clinical
Excellence; SBP, systolic blood pressure.
Evidence-Based Guideline for the Management of Hypertension in Adults (hereafter “JAMA
2014”) published in Journal of the American Medical Association (JAMA) by the group originally
empanelled as Joint National Committee (JNC) 8. Recommendation 4 advised a treatment goal
of less than 140/90 mm Hg and did not recommend an alternate goal in the presence of
proteinuria. Recommendation 8 advised the use of an angiotensin-converting enzyme inhibitor
(ACEI) or an angiotensin receptor blocker (ARB; but not both at the same time) in the
management of hypertension in CKD, either as initial or as add-on therapy, regardless of race
or diabetes status.
The JAMA 2014 Panel defined CKD in a person with hypertension based on the entry criteria of
the studies used in the evidence base. The main component of the definition was a measured or
estimated glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2 in people younger than
70 years. If a urine albumin-to-creatinine ratio was greater than 30 mg to 1 g, then the definition
was not restricted to an age or GFR limit.
In conclusion, among the guidelines that present recommendations for BP management in
patients with CKD, there is far more agreement than differences. There will continue to be many
in the Nephrology community who adhere to a lower treatment target of less than 130/80 mm
Hg when proteinuria is present because it is difficult to ignore the large amount of epidemiologic
evidence supporting proteinuria as an important predictor of kidney function loss.
Pr. Jacques CHANARD
Professor of Nephrology