What is the target blood pressure for a patient with Chronic Kidney Disease (CKD) stage 5?

Target Blood Pressure in CKD Stage 5

For patients with CKD stage 5 (not on dialysis), target a blood pressure of <140/90 mmHg, as the aggressive KDIGO target of <120 mmHg specifically excluded advanced CKD patients and carries substantial risks of acute kidney injury, falls, and hospitalization in this vulnerable population. 1, 2

Critical Context: Why CKD Stage 5 is Different

The 2021 KDIGO guideline recommends systolic BP <120 mmHg for "most patients with CKD not receiving dialysis," but this recommendation is based exclusively on the SPRINT trial, which explicitly excluded patients with CKD stages 4 and 5 (very few stage 4 patients were included). 1 This means the <120 mmHg target has no evidence base in your patient population and represents extrapolation beyond the data. 1

Recommended Blood Pressure Target for CKD Stage 5

Target <140/90 mmHg using standardized measurement techniques. 1, 2, 3 This target is supported by:

• NICE guidelines (2021): Recommend <140/90 mmHg for CKD patients, with lower targets only for those with high albuminuria (ACR >70 mg/mmol). 1, 2
• ESC/ESH guidelines (2018): Recommend systolic BP 130-139 mmHg for CKD patients. 1, 2, 3
• Consensus from multiple trials: Three randomized trials conducted exclusively in CKD patients showed that BP <130/80 mmHg neither saves lives nor protects kidneys or cardiovascular systems compared to <140/90 mmHg. 4

When to Consider a Lower Target (<130/80 mmHg)

Only if your patient has significant proteinuria (>300 mg/day or ACR >300 mg/g) should you consider targeting <130/80 mmHg, as this subgroup may experience delayed renal disease progression. 2, 5, 6 However, even this benefit is not conclusively proven in advanced CKD. 6

Specific Risks of Aggressive BP Lowering in CKD Stage 5

CKD stage 5 patients are particularly vulnerable to:

• Acute kidney injury from hypoperfusion (impaired autoregulation). 3
• Falls and fractures (elderly, multimorbid population). 1
• Increased hospitalization and death from overly aggressive lowering. 1
• U-shaped mortality curve: Both systolic BP <120 mmHg and >180 mmHg are associated with increased death risk in advanced CKD. 2

Measurement Technique Matters

If you choose to target lower BP goals, you must use standardized automated office BP measurement (5-minute rest, average of three readings, ideally unattended). 1, 2 Applying the <120 mmHg target to routine office BP measurements is hazardous and will result in overtreatment. 1, 2

Pharmacologic Approach

• First-line: ACE inhibitor or ARB (especially if albuminuria ≥30 mg/g), which reduces albuminuria beyond BP effects. 2, 3
• Add: Calcium channel blocker or thiazide-like diuretic for resistant hypertension. 7, 2
• Monitor labs: Check basic metabolic panel within 2-4 weeks after initiating or titrating medications to detect hyperkalemia or worsening renal function. 7, 3

Safety Thresholds to Avoid Harm

• Do not allow systolic BP <110 mmHg. 7
• Avoid diastolic BP <70-80 mmHg, which increases cardiovascular risk. 7, 3
• Monitor for hypoperfusion symptoms: Fatigue, light-headedness, orthostatic symptoms, worsening mental status. 7, 3
• Use home BP monitoring to detect hypotension between visits. 7

Key Pitfalls to Avoid

• Never apply the KDIGO <120 mmHg target to CKD stage 5 patients—they were excluded from the supporting evidence (SPRINT). 1, 2
• Do not aggressively lower BP during acute illness, dehydration, or volume depletion in this population with impaired autoregulation. 7, 3
• Recognize that the KDIGO recommendation is an outlier among international guidelines and will confuse clinicians; ACC/AHA, ESC/ESH, and NICE all recommend higher targets. 1

Practical Algorithm for CKD Stage 5

1. Confirm CKD stage 5 (eGFR <15 mL/min/1.73 m², not yet on dialysis). 7
2. Assess proteinuria level (urine albumin-to-creatinine ratio). 7, 2
3. Set target:
   • If ACR <300 mg/g: Target <140/90 mmHg. 1, 2
   • If ACR >300 mg/g: Consider <130/80 mmHg (lowest systolic 120 mmHg). 2, 5
4. Initiate ACE inhibitor or ARB (if not contraindicated). 2, 3
5. Add calcium channel blocker or thiazide diuretic if needed. 7, 2
6. Check labs in 2-4 weeks after medication changes. 7, 3
7. Use home BP monitoring to avoid systolic BP <110 mmHg and diastolic BP <80 mmHg. 7
8. Titrate carefully, monitoring for hypoperfusion symptoms. 7, 3