What is the best approach for blood pressure control in patients with Chronic Kidney Disease (CKD)?

From the Guidelines

The best approach for blood pressure control in patients with Chronic Kidney Disease (CKD) involves targeting a blood pressure goal of less than 120 mmHg, as recommended by the KDIGO 2021 clinical practice guideline 1.

Key Considerations

• The guideline emphasizes the importance of standardized blood pressure measurement and strict control of blood pressure to reduce the risk of cardiovascular disease, mortality, and progression of CKD.
• The use of renin-angiotensin system inhibitors (RASI), such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), is recommended as first-line therapy for patients with CKD and high blood pressure 1.
• Medications like lisinopril, enalapril, losartan, or irbesartan are commonly prescribed to lower blood pressure and reduce proteinuria.
• For patients who don't achieve target blood pressure with an ACEI or ARB alone, adding a thiazide diuretic or a calcium channel blocker may be necessary.

Lifestyle Modifications

• A modest dietary sodium restriction (less than 2.3g daily) and lifestyle modifications, including regular physical activity, weight management, and limiting alcohol consumption, complement pharmacological therapy.
• Regular monitoring of serum creatinine, potassium, and blood pressure is essential, especially when initiating or adjusting medication doses.

Controversies and Limitations

• The recommendation of a systolic blood pressure target of <120 mmHg has been debated, with some arguing that it may not be generalizable to all patients with CKD and may pose safety concerns, particularly in frail or elderly patients 1.
• However, the KDIGO guideline emphasizes the importance of individualized management and consideration of patient characteristics, tolerability, and preferences.

From the FDA Drug Label

The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]). Patients were randomized to receive losartan 50 mg once daily or placebo on a background of conventional antihypertensive therapy excluding ACE inhibitors and angiotensin II antagonists After one month, investigators were instructed to titrate study drug to 100 mg once daily if the trough blood pressure goal (140/90 mmHg) was not achieved.

The best approach for blood pressure control in patients with Chronic Kidney Disease (CKD) is to aim for a trough blood pressure goal of 140/90 mmHg.

• Losartan can be used to help achieve this goal, with a starting dose of 50 mg once daily and titration to 100 mg once daily if necessary.
• The use of losartan has been shown to reduce the risk of doubling of serum creatinine, end-stage renal disease (ESRD), and death in patients with type 2 diabetes and nephropathy 2.
• Conventional antihypertensive therapy can be used in combination with losartan to achieve blood pressure control.
• It is essential to monitor blood pressure and adjust the treatment regimen as needed to achieve the target goal.

From the Research

Blood Pressure Control in CKD

• The optimal control of blood pressure in patients with Chronic Kidney Disease (CKD) is crucial to prevent cardiovascular events and end-stage kidney disease 3.
• Achieving an optimal blood pressure level can reduce the risk of adverse outcomes, and a lower systolic blood pressure target has been accepted by the Kidney Disease: Improving Global Outcomes (KDIGO) 2021 guidelines 3.
• However, whether intensive control of systolic blood pressure targeting < 120 mmHg is effective in patients with CKD is controversial, and this lower target is associated with a higher risk of adverse kidney outcomes 3.

Metabolites Associated with Blood Pressure in CKD

• Certain metabolites have been identified as having significant associations with blood pressure in CKD patients, including aspartylglycosamine, fructose-1,6-diphosphate, and N-Acetylserine 4.
• These metabolites may have potential as supplements to help control blood pressure in CKD patients, although further research is needed to confirm their effectiveness 4.

Discrepancies in Clinic and Ambulatory Blood Pressure in CKD

• Clinic blood pressure measurements may not accurately reflect a patient's overall blood pressure control, and ambulatory blood pressure monitoring (ABPM) can provide a more accurate assessment of blood pressure in CKD patients 5.
• ABPM can help identify patients with non-dipping or reverse-dipping blood pressure patterns, which are associated with a higher risk of cardiovascular complications and kidney disease progression 5.

Ideal Blood Pressure Goal for CKD Patients

• The ideal blood pressure goal for patients with stage III or higher CKD is a topic of debate, but a blood pressure of less than 140/90 mmHg appears to be a reasonable target 6.
• In patients with CKD and proteinuria, a target systolic blood pressure of 120-130 mmHg and diastolic blood pressure of 70-80 mmHg may be beneficial while avoiding adverse cardiovascular outcomes 6.

Association between Blood Pressure Control and Mortality in CKD

• Strict blood pressure control during CKD may be associated with lower mortality after the onset of end-stage renal disease, although the primary results of randomized controlled trials failed to show an impact on kidney disease progression 7.
• Long-term post-ESRD outcomes should be considered when formulating blood pressure targets for CKD patients, and strict blood pressure control may have beneficial effects beyond reducing the risk of end-stage renal disease 7.