What are the recent guidelines for managing blood pressure in patients with Chronic Kidney Disease (CKD)?

Recent Guidelines for Managing Blood Pressure in Chronic Kidney Disease (CKD)

For adults with high blood pressure and CKD, treatment should target a systolic blood pressure (SBP) of <120 mmHg when tolerated, using standardized office BP measurement. 1

Blood Pressure Measurement

• Standardized office BP measurement is crucial and should be used for the management of high BP in adults with CKD 1
• Proper patient preparation is essential: patient should be relaxed in a chair with back supported for >5 minutes, avoid caffeine/exercise/smoking for 30 minutes before measurement, empty bladder, and remove clothing covering cuff placement 1
• Out-of-office BP measurements (home BP monitoring or ambulatory BP monitoring) should complement standardized office readings 1
• Automated oscillometric devices are preferred over manual devices for standardized office BP measurement 1

BP Targets for Different CKD Populations

• Adults with CKD: Target SBP <120 mmHg when tolerated 1
• Kidney transplant recipients: Target BP <130/80 mmHg 1
• Children with CKD: 24-hour mean arterial pressure by ABPM should be lowered to ≤50th percentile for age, sex, and height 1
• Important caveat: It is potentially hazardous to apply the recommended SBP target of <120 mmHg to BP measurements obtained in a non-standardized manner 1, 2

First-Line Antihypertensive Therapy

• For CKD with severely increased albuminuria (A3) without diabetes: Start with renin-angiotensin system inhibitors (RASi) - either ACEi or ARB 1, 2
• For CKD with moderately increased albuminuria (A2) without diabetes: RASi (ACEi or ARB) are suggested 1
• For CKD with moderately-to-severely increased albuminuria (A2 and A3) with diabetes: RASi (ACEi or ARB) are strongly recommended 1, 2
• For kidney transplant recipients: Dihydropyridine calcium channel blocker (CCB) or ARB as first-line therapy 1
• For CKD without albuminuria: RASi may still be reasonable treatment options 1, 2

Monitoring and Management of RASi Therapy

• Use the highest approved dose of RASi that is tolerated to achieve proven benefits 1
• Check BP, serum creatinine, and potassium within 2-4 weeks of initiation or dose increase 1
• Continue ACEi or ARB unless serum creatinine rises by more than 30% within 4 weeks following initiation or dose increase 1
• Hyperkalemia associated with RASi can often be managed by measures to reduce potassium levels rather than decreasing dose or stopping RASi 1, 2
• Consider reducing dose or discontinuing RASi in cases of symptomatic hypotension, uncontrolled hyperkalemia despite treatment, or to reduce uremic symptoms in advanced kidney failure (eGFR <15 ml/min/1.73 m²) 1, 2

Important Contraindications and Precautions

• Avoid any combination of ACEi, ARB, and direct renin inhibitor therapy in patients with CKD 1
• Mineralocorticoid receptor antagonists are effective for refractory hypertension but may cause hyperkalemia or reversible decline in kidney function, particularly in patients with low eGFR 1, 2
• DASH-type diet or potassium-rich salt substitutes may not be appropriate for advanced CKD patients due to hyperkalemia risk 1, 3
• Sodium restriction (<2g sodium per day) is recommended but not appropriate for patients with sodium-wasting nephropathy 1

Lifestyle Modifications

• Target sodium intake <2g per day (<5g sodium chloride) 1
• Recommend moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 1
• Consider cardiorespiratory fitness, physical limitations, cognitive function, and fall risk when implementing physical activity interventions 1, 4

Medication Selection Algorithm

1. First choice: ACEi or ARB, particularly with albuminuria 2, 3
2. If additional BP lowering needed: Add dihydropyridine CCB or thiazide/thiazide-like diuretic 2, 5
3. For resistant hypertension: Consider adding mineralocorticoid receptor antagonist with close monitoring of potassium and renal function 2, 6
4. For kidney transplant recipients: Start with dihydropyridine CCB or ARB 1