What are the recommended blood pressure targets and treatment strategies for patients with hypertension and chronic kidney disease (CKD)?

Hypertension Management in Chronic Kidney Disease

Blood Pressure Targets

Target systolic BP <120 mmHg using standardized office measurement for most adults with CKD not on dialysis, though this recommendation is controversial and requires careful patient selection. 1

• For kidney transplant recipients: Target <130/80 mmHg 1, 2
• For children with CKD: Target mean arterial pressure ≤50th percentile for age, sex, and height 1, 2
• Critical caveat: The <120 mmHg target applies ONLY to standardized BP measurement—applying this to routine office BP is potentially hazardous and may cause overtreatment 1

Controversy Around BP Targets

• The KDIGO <120 mmHg recommendation is based primarily on SPRINT trial subgroup analysis and is an outlier among international guidelines 1
• Alternative guideline targets:
  • ACC/AHA (2017): <130/80 mmHg 1
  • ESC/ESH (2018): 130-139 mmHg systolic 1
  • NICE (2019): <140/90 mmHg (or 120-129 mmHg for high albuminuria) 1
• **Populations where <120 mmHg target has weak evidence:** Patients with diabetes, advanced CKD (G4-G5), proteinuria >1 g/day, very low diastolic BP, white coat hypertension, and extreme ages 1
• Real-world concerns: Risk of falls, fractures, AKI, stroke, polypharmacy complications, and difficulty achieving target in frail/elderly patients 1

Blood Pressure Measurement Techniques

Use standardized office BP measurement with automated oscillometric devices, not routine casual BP readings. 1, 2

Standardized Office BP Protocol

• 5 minutes of quiet rest before measurement 2
• Back supported, feet flat on floor, arm at heart level 2
• Automated office BP (AOBP), attended or unattended, is preferred 1
• Oscillometric devices can be used even in atrial fibrillation 1

Out-of-Office Monitoring

• Use ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to complement office readings 1, 3
• Essential for identifying white coat hypertension, masked hypertension, and abnormal dipping patterns 2

Pharmacologic Treatment Algorithm

First-Line Therapy: RAS Inhibitors

Start ACE inhibitor or ARB as first-line therapy in CKD patients with albuminuria. 1, 2, 3

• Strong recommendation (1B): ACE inhibitor or ARB for CKD with severely increased albuminuria (A3) with or without diabetes 1, 2
• Moderate recommendation (2C): ACE inhibitor or ARB for CKD with moderately increased albuminuria (A2) without diabetes 1, 3
• Reasonable approach: Consider RAS inhibitors even in CKD without albuminuria 1
• Dosing: Titrate to highest approved dose tolerated—proven benefits achieved at maximal doses in trials 1, 2, 3

Monitoring After RAS Inhibitor Initiation

Check BP, serum creatinine, and potassium within 2-4 weeks of starting or increasing ACE inhibitor/ARB dose. 1, 2

• Accept creatinine increases up to 30% within 4 weeks 1, 2
• Continue therapy unless: Creatinine rises >30%, symptomatic hypotension, or uncontrolled hyperkalemia despite treatment 1
• Hyperkalemia management: Use measures to reduce potassium rather than stopping RAS inhibitor when possible 1

Second-Line Therapy

Add long-acting dihydropyridine calcium channel blocker (CCB) as second-line agent. 2, 4

• Dihydropyridine CCBs should not be used as monotherapy in proteinuric CKD—always combine with RAS blocker 4
• Non-dihydropyridine CCBs consistently reduce albuminuria and slow kidney function decline 4

Third-Line Therapy

Add thiazide or loop diuretic as third-line agent, depending on kidney function. 2, 4

• Loop diuretics required when eGFR significantly reduced 4
• Diuretics represent cornerstone management in CKD patients 4

Lifestyle Modifications

Dietary Sodium Restriction

Target sodium intake <2 g/day (<90 mmol/day or <5 g sodium chloride/day). 1, 2

• Exception: Avoid sodium restriction in sodium-wasting nephropathy 1
• Caution with DASH diet/potassium-rich salt substitutes: Not appropriate in advanced CKD or impaired potassium excretion due to hyperkalemia risk 1

Physical Activity

Recommend moderate-intensity physical activity for cumulative 150 minutes per week. 1, 2

• Modify based on cardiorespiratory fitness, physical limitations, cognitive function, and fall risk 1, 2
• Health benefits may occur even below general population targets 1

Protein Intake

Maintain protein intake at 0.8 g/kg/day in CKD G3-G5; avoid high protein intake >1.3 g/kg/day. 2

• Exception: Consider higher protein/calorie targets in elderly and frail patients to prevent sarcopenia 2

Special Population Considerations

Elderly, Frail, and Multimorbid Patients

Accept less aggressive BP targets (<140/80 mmHg) if symptomatic hypotension, high fall risk, or very limited life expectancy. 1, 2

• Clinicians can reasonably offer less intensive BP-lowering therapy in these populations 1

Diabetic CKD

Intensive glycemic control and lipid management are essential adjuncts to BP control. 2

• Multiple medications typically required 2
• Note: ACCORD trial did not support intensive BP targets in diabetes, unlike SPRINT which excluded diabetics 1

Common Pitfalls to Avoid

• Never apply <120 mmHg target to routine office BP measurements—this risks dangerous overtreatment 1
• Do not stop RAS inhibitors for creatinine increases <30%—this is expected and acceptable 1, 2
• Avoid aggressive BP lowering that drives diastolic BP too low—increases cardiovascular risk in CKD patients 1
• Do not use dihydropyridine CCBs alone in proteinuric CKD—always combine with RAS blocker 4
• Recognize that <50% of real-world CKD patients achieve even 130/80 mmHg target—<120 mmHg may be unattainable for most 1