What are the recommended blood pressure targets and treatments to protect kidney function in patients with Chronic Kidney Disease (CKD)?

Blood Pressure Targets in CKD to Protect Kidneys

For most adults with CKD not on dialysis, target a systolic blood pressure <120 mmHg using standardized office measurement, but this aggressive target should be avoided in patients with diabetes, advanced CKD (stages 4-5), or significant proteinuria where <130/80 mmHg is more appropriate. 1, 2

Blood Pressure Measurement Method

The target BP depends critically on how you measure it:

• Use standardized office BP measurement (automated oscillometric device, proper patient preparation) rather than routine office BP 1
• The <120 mmHg target cannot be applied to routine office BP readings because the relationship between routine and standardized BP is highly variable 1, 2
• Consider out-of-office monitoring (ambulatory BP monitoring or home BP monitoring) to complement office readings 1

Specific BP Targets by Patient Population

Non-Diabetic CKD Without Significant Proteinuria

• Target systolic BP <120 mmHg using standardized measurement 1
• This is based on SPRINT trial data showing cardiovascular and mortality benefits (though no direct kidney protection) 2
• If using routine office BP, target <140/90 mmHg instead 2

CKD With Significant Proteinuria (>300 mg/day or ACR >300 mg/g)

• Target BP <130/80 mmHg 2, 3
• Subgroup analyses suggest lower BP targets provide greater benefit specifically in patients with higher proteinuria levels 3
• The <120 mmHg target should be avoided in this population due to insufficient evidence 1, 2

CKD With Diabetes

• Target BP <130/80 mmHg 2, 4
• The ACCORD trial showed no overall cardiovascular benefit at <120 mmHg in diabetic patients 2
• Do not use the aggressive <120 mmHg target 1, 2

Advanced CKD (Stages 4-5, Not on Dialysis)

• Target BP <140/90 mmHg 2, 5
• The <120 mmHg KDIGO target does not apply to advanced CKD patients who were excluded from supporting trials 2, 5
• These patients face increased risks of acute kidney injury, falls, and fractures with aggressive BP lowering 2, 5

Kidney Transplant Recipients

• Target BP <130/80 mmHg 1

Pharmacologic Treatment Strategy

First-Line Agents

For CKD with albuminuria ≥30 mg/g:

• Start ACE inhibitor or ARB as first-line therapy 1, 4
• Specifically recommended for:
  • Severely increased albuminuria (A3) without diabetes (CKD stages G1-G4) 1
  • Moderately-to-severely increased albuminuria (A2-A3) with diabetes 1
  • Moderately increased albuminuria (A2) without diabetes (weaker recommendation) 1
• These agents reduce albuminuria beyond BP effects and slow CKD progression 2, 6

Critical contraindication:

• Never combine ACE inhibitor + ARB + direct renin inhibitor 1

Additional Agents for Resistant Hypertension

• Add dihydropyridine calcium channel blocker or thiazide-type diuretic 2, 4
• Non-dihydropyridine CCBs reduce albuminuria but should not be used as monotherapy in proteinuric CKD 4
• Dihydropyridine CCBs should always be combined with a RAAS blocker in proteinuric patients 4

Lifestyle Modifications

• Sodium restriction: Target <2 g sodium per day (<90 mmol/day or <5 g sodium chloride/day) 1
  • Exception: Do not restrict sodium in patients with sodium-wasting nephropathy 1
• Physical activity: Moderate-intensity exercise for cumulative 150 minutes per week 1
• Avoid DASH diet or potassium-rich salt substitutes in advanced CKD due to hyperkalemia risk 1

Critical Pitfalls to Avoid

• Do not apply the <120 mmHg target using routine office BP - it only applies to standardized measurement 1, 2
• Avoid aggressive BP lowering (<120 mmHg) in diabetes, advanced CKD (stages 4-5), or significant proteinuria 1, 2
• Do not lower diastolic BP below 70 mmHg - this increases cardiovascular risk in CKD patients 5
• Never use triple RAAS blockade (ACE inhibitor + ARB + direct renin inhibitor) 1
• Recognize that evidence for kidney protection at <120 mmHg is "almost non-existent" except possibly in patients with proteinuria 2, 3

Evidence Quality Considerations

The KDIGO <120 mmHg recommendation is based on SPRINT trial data, but this represents a single study with less compelling evidence than placebo-controlled trials 1. The evidence supporting this aggressive target is less rigorous in subpopulations with diabetes, advanced CKD, significant proteinuria, very low diastolic BP, and extreme ages 1. Multiple trials comparing lower versus standard BP targets in CKD show no significant reduction in total mortality, cardiovascular events, or progression to ESRD 2. For patients without significant proteinuria, the more conservative target of <140/90 mmHg is reasonable and evidence-based 2, 7, 8.