Definition of Hypertension in Chronic Kidney Disease
Hypertension in CKD is defined as blood pressure ≥130/80 mmHg, which represents the threshold at which treatment should be initiated and the target below which blood pressure should be controlled. 1
Blood Pressure Threshold and Diagnostic Criteria
The 2017 ACC/AHA guidelines fundamentally redefined hypertension in CKD patients by lowering the diagnostic and treatment threshold from the previous 140/90 mmHg to <130/80 mmHg for all adults with CKD. 1 This represents both the definition of hypertension and the treatment target in this population.
- All CKD patients with BP ≥130/80 mmHg meet criteria for hypertension requiring treatment, regardless of CKD stage or presence of diabetes. 1
- This definition applies uniformly across CKD stages 1-4 (patients not on dialysis). 1
- The threshold is the same whether patients have diabetic kidney disease or non-diabetic CKD. 1
Rationale for the Lower Threshold
The redefinition stems from SPRINT trial data showing that intensive BP control (target <120 mmHg systolic) reduced cardiovascular events and all-cause mortality in CKD patients. 1 Since most CKD patients die from cardiovascular complications rather than progressing to end-stage renal disease, the lower threshold prioritizes cardiovascular risk reduction. 1
- CKD patients comprised 28% of SPRINT participants, and intensive BP management provided the same cardiovascular benefits as seen in the full cohort. 1
- CKD itself is an independent risk factor for cardiovascular disease, and the coexistence of hypertension and CKD substantially increases cardiovascular and cerebrovascular event risk. 1
Prevalence and Clinical Context
Hypertension affects 67% to 92% of patients with CKD, with prevalence increasing as kidney function declines. 1 The relationship is bidirectional: hypertension may result from kidney disease, yet also accelerates further kidney injury. 1
- Masked hypertension occurs in up to 30% of CKD patients and portends higher risk of CKD progression, making out-of-office BP monitoring particularly important in this population. 1
Key Distinction from Previous Definitions
Prior to 2017, most guidelines defined hypertension in CKD as BP <140/90 mmHg, with consideration of <130/80 mmHg only for those with severe proteinuria (≥300 mg albuminuria per 24 hours). 1 The current definition eliminates this distinction—all CKD patients now have the same <130/80 mmHg threshold regardless of proteinuria level. 1
Measurement Considerations
The definition assumes standardized office BP measurements, preferably using an automated device. 1 For 24-hour ambulatory BP monitoring, the corresponding goal is <125/75 mmHg. 1