What is the goal blood pressure for a patient with Human Immunodeficiency Virus (HIV) and Chronic Kidney Disease (CKD) stage 3a?

Blood Pressure Goal for 68-Year-Old with HIV and CKD 3a

The goal blood pressure is <140/90 mm Hg if albuminuria is <30 mg/day, or <130/80 mm Hg if albuminuria is ≥30 mg/day. 1

Primary Recommendation Based on Albuminuria Status

The HIV Medicine Association of the Infectious Diseases Society of America provides specific guidance for this exact population:

• For normal or mildly increased albuminuria (<30 mg/day): Target BP <140/90 mm Hg (strong recommendation, moderate-quality evidence) 1
• For moderately to severely increased albuminuria (≥30 mg/day): Target BP <130/80 mm Hg (weak recommendation, low-quality evidence) 1

This albuminuria-stratified approach is critical because the patient's proteinuria level determines whether more aggressive BP control provides benefit or simply increases treatment burden and adverse effects. 1

Supporting Evidence from General CKD Guidelines

The 2017 ACC/AHA guidelines recommend a BP goal of <130/80 mm Hg for all adults with CKD, which would apply to this patient. 1 The 2019 KDOQI commentary reinforces this target for CKD patients. 1 However, these general CKD recommendations do not account for the HIV-specific evidence showing that lower BP targets lack benefit in patients without significant proteinuria. 1

Why Albuminuria Status Matters

Three major trials (MDRD, AASK, and REIN-2) demonstrated that **lower BP targets (<130/80 mm Hg) were not associated with statistically significant improvements in mortality or ESRD risk in the overall CKD population.** 1 However, subgroup analyses from AASK and MDRD trials showed benefit specifically in patients with proteinuria >300-1000 mg/day. 1, 2

Practical Implementation Algorithm

Step 1: Measure urine albumin-to-creatinine ratio or 24-hour urine albumin

Step 2: Apply BP target based on result:

• If <30 mg/day: Target <140/90 mm Hg 1
• If ≥30 mg/day: Target <130/80 mm Hg 1

Step 3: Initiate or adjust antihypertensive therapy:

• ACE inhibitor or ARB should be included in the regimen for CKD patients, particularly if albuminuria is present 1
• Monitor GFR and potassium within 1 week of starting or dose escalation 1
• Follow up every 6-8 weeks until BP goal achieved 1

Critical Caveats for This 68-Year-Old Patient

Age considerations: At 68 years old, this patient falls into a category where careful monitoring is essential. 1 When targeting lower BP goals, monitor for:

• Orthostatic hypotension and syncope 1
• Fatigue and light-headedness 1
• Acute kidney injury during intercurrent illness 1

Patient education is mandatory: Instruct the patient to hold or reduce antihypertensive medications during vomiting, diarrhea, or decreased oral intake to prevent volume depletion and AKI. 1

Drug-drug interactions: If the patient is on antiretroviral therapy with protease inhibitors, be cautious with statin selection (atorvastatin, pravastatin, rosuvastatin, or pitavastatin are preferred). 1

Common Pitfall to Avoid

Do not automatically apply the general ACC/AHA <130/80 mm Hg target without first assessing albuminuria. 1 The HIV-specific guidelines provide stronger evidence (strong recommendation) for the <140/90 mm Hg target in patients without significant albuminuria, whereas the lower target has only weak evidence and may increase pill burden and adverse events without clinical benefit. 1