KDIGO Blood Pressure Guidelines for Chronic Kidney Disease
Primary Blood Pressure Target
The 2021 KDIGO guideline recommends targeting a systolic blood pressure <120 mmHg using standardized office measurement for most adults with CKD not on dialysis. 1, 2, 3 This represents a major shift from the 2012 KDIGO guideline, which recommended <140/90 mmHg for patients without albuminuria and <130/80 mmHg for those with albuminuria ≥30 mg/24h. 4
Critical Measurement Requirement
This <120 mmHg target applies ONLY to standardized office blood pressure measurements, not routine casual office readings. 2, 3, 5 Using casual office BP readings with this target risks dangerous overtreatment. 3
Standardized measurement requires: 5 minutes of quiet rest, back supported, feet flat on floor, arm at heart level, using automated oscillometric devices. 2, 3
Out-of-office monitoring (home BP or ambulatory BP monitoring) should complement standardized office readings to identify white coat hypertension, masked hypertension, and abnormal dipping patterns. 1, 2
Pharmacologic Treatment Algorithm
First-Line Therapy
For CKD patients with severely increased albuminuria (≥300 mg/g or ≥30 mg/24h), start with ACE inhibitor or ARB as first-line therapy. 1, 2, 3 This applies to both diabetic and non-diabetic patients. 2
For moderately increased albuminuria (30-300 mg/g), ACE inhibitor or ARB are also suggested. 1
Titrate to the highest approved dose tolerated, as proven benefits in clinical trials were achieved using maximal doses. 1, 2
Monitoring After RAS Inhibitor Initiation
Check BP, serum creatinine, and serum potassium within 2-4 weeks of starting or increasing ACE inhibitor/ARB dose. 2, 3
Accept serum creatinine increases up to 30% within 4 weeks—do not stop RAS inhibitors for this expected physiologic response. 2, 3
Second and Third-Line Therapy
Add a long-acting dihydropyridine calcium channel blocker as second-line therapy. 2, 3
Add a thiazide diuretic (if eGFR ≥30 mL/min/1.73m²) or loop diuretic (if eGFR <30 mL/min/1.73m²) as third-line therapy. 2, 3
Lifestyle Modifications
Target sodium intake <2 g/day (<90 mmol/day or <5 g sodium chloride/day). 1, 2, 3
Engage in moderate-intensity physical activity for cumulative 150 minutes per week, with modifications based on cardiorespiratory fitness, physical limitations, cognitive function, and fall risk. 1, 2, 3
Maintain protein intake at 0.8 g/kg/day in CKD G3-G5, and avoid high protein intake >1.3 g/kg/day. 2, 3
Special Population Considerations
Kidney Transplant Recipients
- Target BP remains <130/80 mmHg for kidney transplant recipients, not the more aggressive <120 mmHg target. 2
Elderly, Frail, and Multimorbid Patients
Accept less aggressive BP targets (<140/80 mmHg) if symptomatic hypotension, high fall risk, or very limited life expectancy. 2, 3
Consider higher protein and calorie targets to prevent sarcopenia in elderly and frail patients. 2
Children with CKD
- Target 24-hour mean arterial pressure ≤50th percentile for age, sex, and height using ambulatory BP monitoring. 2
Key Controversies and Pitfalls
Divergence from Other Guidelines
The 2021 ESC/ESH guidelines recommend a higher target of 130-139 mmHg systolic BP for most adults with CKD, creating significant confusion for clinicians. 3, 6
The ACC/AHA guidelines recommend <130/80 mmHg, which is intermediate between KDIGO and ESC recommendations. 3
Evidence Base Limitations
The <120 mmHg recommendation is based primarily on the SPRINT trial CKD subgroup analysis, which excluded patients with diabetes, advanced CKD (eGFR <20 mL/min/1.73m²), and proteinuria >1 g/day. 7, 5, 8
The evidence for this aggressive target in diabetic CKD patients is weak, as ACCORD-BP showed no benefit from intensive BP lowering in diabetics. 8
Avoid driving diastolic BP too low during aggressive systolic BP lowering, as this increases cardiovascular risk in CKD patients. 3