What is the recommended blood pressure (BP) target for reducing cardiovascular complications in patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD) and renal disease progression?

Blood Pressure Target for ADPKD Patients

According to the JNC VIII report, a blood pressure target of 140/90 mmHg is recommended for reducing cardiovascular complications in ADPKD and slowing renal disease progression. 1

Evidence-Based BP Targets in ADPKD

• The 2019 KDOQI US Commentary on the 2017 ACC/AHA Hypertension Guideline recommends that adults with hypertension and CKD (which includes ADPKD) should be treated to a BP goal of less than 130/80 mm Hg 1
• However, the JNC VIII report specifically recommended a target of <140/90 mmHg for persons aged 18 to 69 years with eGFRs <60 mL/min/1.73 m² or in people of any age with albuminuria 1
• The 2025 KDIGO guidelines for ADPKD recommend different targets based on age and CKD stage:
  • For patients aged 18-49 years with CKD G1-G2: target BP of ≤110/75 mm Hg if tolerated 1
  • For patients aged ≥50 years and/or with CKD G3-G5: target systolic BP of <120 mm Hg if tolerated 1

Impact of BP Control on ADPKD Outcomes

• Hypertension is a common early finding in ADPKD, occurring in 50-70% of patients before renal function impairment 2
• Cardiovascular complications are a major cause of morbidity and mortality in ADPKD patients 2, 3
• The HALT-PKD Study demonstrated significant benefits of a lower BP goal (95/60 to 110/75 mmHg) versus standard BP target (120/70 to 130/80 mmHg) in terms of:
  • Slower increase in total kidney volume
  • Greater decline in left ventricular mass index
  • Greater reduction in urinary albumin excretion 4
• Rigorous BP control prevents increases in left ventricular mass index and reduces urinary albumin excretion, suggesting a crucial role in slowing progression of cardiac and renal damage in ADPKD 5

First-Line Treatment Recommendations

• Renin-angiotensin system inhibitors (ACEi or ARBs) are recommended as first-line treatment for hypertension in ADPKD 1
• ACE inhibitors and ARBs have the largest evidence base for efficacy and safety in patients with renal hypertension 1
• Calcium channel blockers should be used with caution in ADPKD as they may promote cyst growth in animal models, though human study findings are inconsistent 1
• Diuretics should also be used cautiously as they may increase vasopressin levels and have deleterious effects on eGFR compared to ACE inhibitors in ADPKD 1

Monitoring Recommendations

• Ambulatory blood pressure monitoring (ABPM) is recommended for prompt diagnosis of hypertension in ADPKD patients 6
• Home blood pressure measurements can be useful to assess changes over time and monitor treatment 1
• After initiating or adjusting antihypertensive medications, follow-up every 6-8 weeks is recommended until BP goal is safely achieved 1
• Once target BP is achieved, laboratory monitoring and clinic follow-up should occur every 3-6 months 1

Potential Pitfalls and Caveats

• Dizziness and light-headedness are more common with rigorous BP control (80.7% vs. 69.4% with standard control) 4
• Isolated nighttime hypertension with normal daytime BP has been reported in 16-18% of children with ADPKD, highlighting the importance of ABPM 1
• Monitoring for changes in symptoms, including fatigue and light-headedness, is important when targeting lower BP goals 1
• Patients should be instructed to hold or reduce antihypertensive medication doses during periods of decreased oral intake, vomiting, or diarrhea to prevent volume depletion and acute kidney injury 1