What are the recommended blood pressure goals for patients with Chronic Kidney Disease (CKD)?

From the Guidelines

The recommended blood pressure goal for patients with chronic kidney disease (CKD) is generally less than 130/80 mmHg, as this target is supported by the most recent and highest quality studies, including the 2021 KDIGO clinical practice guideline 1 and the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1. For CKD patients with albuminuria (protein in the urine), maintaining this target is particularly important to slow kidney disease progression. First-line medications typically include angiotensin-converting enzyme (ACE) inhibitors like lisinopril (starting at 10mg daily) or angiotensin receptor blockers (ARBs) such as losartan (starting at 50mg daily), as these medications provide both blood pressure control and kidney protection by reducing proteinuria 1. Some studies, such as the KDIGO 2021 guideline, suggest a target systolic blood pressure of less than 120 mmHg, but this is based on standardized office measurements and may not be applicable to routine clinical practice 1. In fact, other studies have argued that this target may be inappropriate for many CKD patients and could lead to adverse events such as falls and fractures 1. Most CKD patients require multiple medications to achieve target blood pressure; common combinations include adding a thiazide diuretic like chlorthalidone (12.5-25mg daily) or a calcium channel blocker such as amlodipine (5-10mg daily). Blood pressure should be monitored regularly, ideally with home measurements in addition to clinic readings. Lifestyle modifications are also essential, including sodium restriction to less than 2g daily, regular physical activity, maintaining healthy weight, limiting alcohol consumption, and following a DASH-style diet. These targets are important because hypertension accelerates kidney damage through increased intraglomerular pressure and vascular injury, while proper control significantly slows CKD progression and reduces cardiovascular complications, which are the leading cause of death in CKD patients. Key considerations in managing blood pressure in CKD patients include:

• Individualization of treatment based on patient characteristics, tolerability, and preferences
• Use of standardized blood pressure measurements to guide treatment decisions
• Monitoring for potential adverse effects of blood pressure lowering, such as acute kidney injury and electrolyte abnormalities
• Consideration of the potential benefits and risks of more intensive blood pressure control in different patient subpopulations.

From the Research

Blood Pressure Goals in CKD

The recommended blood pressure goals for patients with Chronic Kidney Disease (CKD) vary depending on the presence of proteinuria and other factors.

• For patients with nondiabetic CKD, a blood pressure goal of less than 140/90 mmHg is generally recommended 2, 3, 4.
• However, for patients with CKD and proteinuria, a lower blood pressure goal of less than 130/80 mmHg may be beneficial in delaying renal disease progression 2, 5, 6.
• The American guidelines recommend a blood pressure goal of less than 130/80 mmHg for patients with established CKD and/or diabetes with albuminuria 5.
• It is also important to note that blood pressure control is important, and hypertension therapy should be individualized, with home blood pressure measurements used to diagnose, monitor, and treat hypertension 3.

Factors Influencing Blood Pressure Goals

Several factors can influence the blood pressure goals in CKD patients, including:

• Presence of proteinuria: Patients with proteinuria may benefit from a lower blood pressure goal of less than 130/80 mmHg 2, 5, 6.
• Level of kidney function: Patients with more advanced CKD may require more aggressive blood pressure control 6.
• Presence of other comorbidities: Patients with other comorbidities, such as cardiovascular disease, may require more individualized blood pressure goals 6.

Treatment Options

The treatment options for hypertension in CKD patients include:

• Lifestyle modifications: Lifestyle modifications, such as diet and exercise, can help to lower blood pressure 5.
• Medications: Medications, such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and diuretics, can be used to lower blood pressure 5.
• Combination therapy: Combination therapy, using multiple medications, may be necessary to achieve blood pressure goals 5.