What is the recommended blood pressure target in patients with Chronic Kidney Disease (CKD)?

Blood Pressure Target in Chronic Kidney Disease

For most adults with CKD and hypertension, target a blood pressure of <130/80 mmHg, with consideration of <120 mmHg systolic (using standardized measurement) in select patients without diabetes, advanced CKD, or significant proteinuria. However, the evidence supporting aggressive targets remains controversial and varies significantly across major guidelines.

Guideline Landscape: Significant Divergence

The major international guidelines provide conflicting recommendations based on the same evidence base:

• KDIGO (2021): Recommends systolic BP <120 mmHg using standardized office measurement 1
• ACC/AHA (2017): Recommends <130/80 mmHg 1
• ESC/ESH (2018): Recommends systolic BP 130-139 mmHg 1
• NICE (2019-2021): Recommends <140/90 mmHg for most CKD patients, with <130/80 mmHg (lowest systolic 120 mmHg) only for those with high albuminuria (ACR >70 mg/mmol) 1

This lack of consensus reflects genuine uncertainty in the evidence base and should inform your clinical approach.

Evidence Base and Limitations

The SPRINT Trial Foundation

The KDIGO recommendation for <120 mmHg systolic is based primarily on the SPRINT trial's CKD subgroup analysis, which showed cardiovascular and mortality benefits but no renoprotective effect 1. However, this evidence has critical limitations:

• SPRINT excluded patients with diabetes (the largest CKD population worldwide), ADPKD, glomerulonephritis on immunosuppression, proteinuria >1 g/day, and CKD stages 4-5 1
• The ACCORD trial in diabetic patients showed no overall cardiovascular benefit at the <120 mmHg target, though stroke reduction was observed 1
• SPRINT used standardized BP measurement (automated, unattended), not routine office BP, making the target potentially hazardous if applied to standard measurements 1

Meta-Analysis Evidence

Multiple trials comparing lower versus standard BP targets in CKD show:

• No significant reduction in total mortality (RR 0.90,95% CI 0.76-1.06) 2
• No significant reduction in cardiovascular events (RR 1.00,95% CI 0.87-1.15) 2
• No significant reduction in progression to ESRD (RR 0.94,95% CI 0.80-1.11) 2
• Historical trials (MDRD, REIN-2, AASK) showed no significant cardiovascular benefit with lower BP targets 1

Practical Clinical Algorithm

Step 1: Stratify by Proteinuria Level

For patients with significant proteinuria (>300 mg/day or ACR >300 mg/g):

• Target BP <130/80 mmHg 3, 4
• Lower targets may provide greater renoprotective benefit in this subgroup 3, 5
• Use ACE inhibitor or ARB as first-line therapy 3, 4

For patients without significant proteinuria (ACR <300 mg/g):

• Target BP <140/90 mmHg is reasonable and evidence-based 1, 6
• Consider <130/80 mmHg for cardiovascular risk reduction in younger, non-frail patients 4

Step 2: Identify High-Risk Populations for Aggressive Lowering

Avoid aggressive BP targets (<120 mmHg systolic) in:

• Patients with diabetes (ACCORD showed no benefit) 1
• Advanced CKD (stages 4-5) - very limited trial data 1
• Elderly or frail patients (increased risk of falls, AKI, fractures) 1, 3, 4
• Baseline systolic BP 120-129 mmHg 1
• Low baseline diastolic BP (<60 mmHg) - risk of coronary hypoperfusion 1
• Patients on dialysis (KDIGO explicitly excludes this population) 1, 7

Step 3: Measurement Method Matters

If pursuing targets <130 mmHg systolic:

• Use standardized BP measurement (automated, unattended after 5 minutes rest) when possible 1
• Do not apply the <120 mmHg target using routine office BP - this increases adverse event risk 1
• Consider home BP monitoring or ambulatory BP monitoring for accurate assessment 8

Step 4: Monitor for Adverse Events

Common pitfalls with intensive BP lowering:

• Acute kidney injury (monitor creatinine within 2-4 weeks of changes) 4
• Hyperkalemia (especially with RAAS blockade) 4
• Orthostatic hypotension (measure BP at 1 and 3 minutes after standing in elderly) 4
• Falls and fractures in frail elderly 1, 4
• Excessive diastolic BP lowering (<60 mmHg) may increase cardiovascular events 1
• Polypharmacy-related complications (drug interactions, non-adherence) 1

Pharmacologic Approach

First-line therapy for CKD with albuminuria ≥30 mg/g:

• ACE inhibitor or ARB reduces albuminuria beyond BP effects and slows CKD progression 4, 9
• The RENAAL trial showed losartan reduced doubling of serum creatinine by 25% and ESRD by 29% in diabetic nephropathy 9

If BP not controlled with ACE inhibitor/ARB alone:

• Add calcium channel blocker or thiazide-type diuretic 4
• For resistant hypertension, consider mineralocorticoid receptor antagonist (finerenone has lower hyperkalemia risk than spironolactone) 4

For elderly patients:

• Avoid beta-blockers and alpha-blockers unless specifically indicated (e.g., post-MI for beta-blockers) 4
• Alpha-1 blockers associated with higher heart failure incidence 4

Special Population: Dialysis Patients

For hemodialysis patients (CKD stage 5D):

• Target pre-dialysis BP <140/90 mmHg and post-dialysis <130/80 mmHg 7
• The <120 mmHg KDIGO target does NOT apply to dialysis patients 1, 7
• U-shaped mortality curve exists: systolic BP <120 mmHg and >180 mmHg both associated with increased death risk 7
• Out-of-dialysis-center BP measurements better predict outcomes than in-center measurements 7
• Emphasize salt restriction and achieving dry weight 7

Critical Caveats

Real-world feasibility concerns:

• Only 50% of CKD patients achieve even the modest <130/80 mmHg target in clinical practice 1
• Approximately 70% have systolic BP ≥120 mmHg despite treatment 1
• Standardized BP measurement is challenging outside research settings and specialist clinics 1

The evidence quality is moderate at best:

• KDIGO's <120 mmHg recommendation is graded 2B (weak recommendation, moderate evidence) 1
• Based on single trial (SPRINT) subgroup analysis 1
• No adequately powered RCTs specifically designed for CKD populations 7