In Practice: Updated Guidelines for Managing Blood Pressure in Patients With Chronic Kidney Disease

Updated recommendations in managing blood pressure (BP) in chronic kidney disease (CKD), the first in nearly a decade, have sparked discussion about how this translates to clinical practice.

Cleveland Clinic nephrologists George Thomas, MD, and Crystal Gadegbeku, MD, Chair of the Department of Nephrology and Hypertension, elaborate on new efforts to standardize blood pressure for patients with CKD in an editorial recently published in the Annals of Internal Medicine.

The KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease outlines new recommendations, some of which address standardizing BP measurements and decreasing the BP goal.

Emphasis on properly obtaining measurement

“For context,” explains Dr. Thomas, “BP measurement was not emphasized in the prior 2012 KDIGO guidelines. There used to be an assumption that all providers were obtaining BP measurements in the recommended way, but this is not the case. There is a new awareness of this now and a focus on moving toward a recommended standardized approach.”

The American Heart Association (AHA) also endorses this strategy to manage hypertension.

Inaccurate measurements can lead to disease mismanagement and hinder efforts to achieve more ambitious target BP goals.

“Patients and providers can benefit equally from an apples-to-apples approach to obtaining a BP measurements, and these updated recommendations move this conversation to the forefront,” says Dr. Thomas.

Implementation and strategies to improve standardization

The KDIGO guidelines provide a comprehensive approach to proper BP evaluation in patients with CKD, but broader adoption requires appropriate education and training for both clinical teams and patients, the physicians say. Automated oscillometric BP devices with programmable features may help facilitate standardization and collection of multiple BP readings in the office.

They also note the importance of implementing out-of-office BP monitoring as an adjunct to in-office monitoring to mitigate the “white coat effect,” which can lead to artifactual readings.

What is the BP goal? How do we get there?

Per the 2021 KDIGO guidelines, a goal systolic BP for patients with CKD using a standardized BP measurement should be less than 120 mm Hg. The condition of this more conservative target, says Dr. Thomas, is that the measurement must be taken properly.

Notably, the new target also represents a shift from the 2017 AHA guidelines, which recommend a target BP of less than 130 mm Hg.

The KDIGO recommendation of BP < 120 mm Hg, they note, is based on findings from SPRINT (Systolic Blood Pressure Intervention Trial), with one caveat: target BPs among CKD subgroups, specifically patients with diabetes, advanced CKD or heavy proteinuria, are not well-defined.

“The KDIGO guidelines extrapolate the findings from the SPRINT study, which include only a subset of CKD patients; therefore, it’s prudent to use the updated guideline judiciously in practice, not as a blanket approach,” he says.

Reinforcing the treatment paradigm…for now

The guidelines also reinforce the treatment paradigm in patients with CKD, which often includes the use of renin-angiotensin system inhibitors, which are well-supported in the literature.

However, there is still “room for improvement,” the authors say, noting some hesitation among providers about using these medications because of potential risks associated with AKI and hyperkalemia, although close patient monitoring, dietary counseling and potassium binders can help support the safe use of this therapy.

Simplifying inherently complex management

“Managing BP in CKD patients is inherently complex; it requires multiple medications and, very likely, escalation of treatment to achieve an ideal BP. Additionally, there is limited guidance on add-on or combination therapies or lifestyle modifications,” says Dr. Thomas. But there is reason to be hopeful about the future of care for these patients.

Although not mentioned in the guidelines, novel therapies, including mineralocorticoid antagonists and sodium–glucose cotransporter-2 inhibitors, are on the horizon. And the growing consensus about standardization of BP measurements, applicable to a wide range of clinicians, represents a practical and immediate first step in shifting practice.