Is the KDIGO Systolic Blood Pressure Target <120 mm Hg for Chronic Kidney Disease Appropriate in Routine Clinical Practice?

Abstract

Meticulous management of hypertension is important in chronic kidney disease (CKD) to reduce the risk of cardiovascular disease, mortality, and progression of CKD. The recently published Kidney Disease Improving Global Outcomes (KDIGO) guideline on blood pressure (BP) management in CKD stresses the importance of standardized BP measurement and strict control of BP. This is a useful document that will help to improve the management of hypertension in CKD globally. However, the recommendation of systolic BP target of &lt;120 mm Hg by KDIGO is controversial. It is based on weak evidence derived mainly from a single randomized controlled trial and its CKD subgroup analysis. Here, we review the current evidence surrounding BP target in CKD. We argue that the target recommended by KDIGO is not generalizable to the majority of people with CKD. Standardized BP measurements are challenging to implement outside specialist hypertension and research clinics, and the target of &lt;120 mm Hg BP systolic cannot be extrapolated to routine clinic BP measurements. If applied to routine BP measurement, this target will expose the multimorbid and frail CKD patients to the risk of adverse events including falls and fractures. Furthermore, it will not be achievable in the majority of CKD patients. The target recommended by KDIGO is an outlier among contemporary major international hypertension guidelines and is likely to perplex clinicians. We believe the KDIGO-recommended target systolic BP &lt;120 mm Hg for CKD is inappropriate in the majority of CKD patients and it may even be harmful for patients managed in routine clinical practice.

Individualisierung der antihypertensiven Therapie bei Patient:innen mit Diabetes mellitus. Leitlinie der Österreichischen Diabetes Gesellschaft (Update 2023)

“…Eine internationale Expertengruppe hat für KDIGO (Kidney Disease Improving Global Outcomes) evidenzbasierte Richtlinien für die antihypertensive Behandlung von Diabetes-Patient:innen mit chronischer Nierenerkrankung festgelegt, die 2021 in überarbeiteter Version veröffentlicht wurden [ 48 ]. Es wird hier für Patient:innen mit chronischer Niereninsuffizienz ein strenger Zielwert für den systolischen Blutdruck von < 120 mm Hg, sofern toleriert gefordert [ 55 ], wobei diese Empfehlung kontrovers diskutiert wird [ 56 ].…”

Blood Pressure and Chronic Kidney Disease Progression: An Updated Review

“…In CKD, careful HTN control is critical to slow the progression of the disease. The importance of BP measurement and strict BP control are emphasized in the recent Kidney Disease Improving Global Outcomes (KDIGO) guidelines on BP therapy in CKD [28]. Although the recent KDIGO guidelines recommend a systolic BP target of <120 mmHg, the recommendation has been controversial because it is based on limited data from only one randomized controlled trial and its CKD subgroup analysis [16].…”

“…Moreover, the newly recommended systolic BP in the new KDIGO guidelines is an outlier among current major international HTN guidelines, which may confuse clinicians in the future. Therefore, the new systolic BP target of <120 mmHg established by KDIGO for CKD patients may be harmful and inappropriate for the majority of the CKD patients [28].…”

Thiazide diuretics are back in CKD: the case of chlorthalidone

“…These guidelines recommend lower systolic BP <120 mmHg ‘if tolerated’. However, even the less ambitious and better justified systolic BP target of <130 mmHg [ 28 ] is difficult to achieve in clinical practice [ 29–34 ]. Inadequate BP control in CKD patients is not limited to office measurements but extends to 24-hour ABP monitoring.…”