Management of Blood Pressure in Chronic Kidney Disease Clinical Practice Guideline (KDIGO, 2021)

Kidney Disease: Improving Global Outcomes

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 31, 2021

An updated guideline on the management of blood pressure (BP) in chronic kidney disease (CKD) was published in March 2021 by Kidney Disease: Improving Global Outcomes (KDIGO) in Kidney International.[1,2]

Key recommendations are summarized below, including treating adults with CKD not on dialysis to a target systolic BP (SBP) below 120 mmHg, a major update from the 2012 KDIGO guideline (which advised clinicians to treat to a target BP of ≤130/80 mmHg for patients with albuminuria or ≤140/90 mmHg for those without albuminuria). This new goal is also lower than the less than 130/80 mmHg target in the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline.[1,2] The public health implications of this updated guideline indicate that 70% of US adults with CKD would now be eligible for treatment to lower BP, relative to 50% under the previous KDIGO guideline and 56% under the ACC/AHA guideline.[2,3]

BP Measurement

Standardized office BP measurement is preferred to routine office measurement for managing adult high BP.

For managing high BP, it is suggested complementing standardized office BP measurements with out-of-office readings (with ambulatory BP measurement [ABPM]) or home BP monitoring (HBPM).

Lifestyle Interventions for Lowering BP in CKD (not receiving dialysis)

Targeting a daily intake of less than 2 g of sodium (or <90 mmol of sodium daily, or <5 g of sodium chloride daily) is suggested in patients with high BP and CKD.

Advising patients with high BP and CKD to engage in moderate-intensity physical activity for a total of at least 150 minutes per week is suggested, or to a level compatible with their cardiovascular and physical tolerance.

CKD ± Diabetes, Not Receiving Dialysis

When tolerated, a target SBP below 120 mmHg is suggested in adults with high BP and CKD, using standardized BP measurement.

For nondiabetics who have high BP, CKD, and severely elevated albuminuria (G1–G4, A3), initiate renin-angiotensin-system inhibitors (RASI) (angiotensin-converting enzyme inhibitor [ACEI] or angiotensin II receptor blocker [ARB])

For nondiabetics with high BP, CKD, and moderately elevated albuminuria (G1-G4, A2), initiating RASI (ACEI or ARB) is suggested.

For diabetics with high BP, CKD, and moderately-to-severely increased albuminuria (G1-G4, A2 and A3), initiate RASI (ACEI or ARB).

Avoid any combination of ACEI, ARB, and direct renin inhibitor (DRI) therapy in patients with CKD, with or without diabetes.

Kidney Transplant Recipients (CKD G1T-G5T)

Treat adult kidney transplant recipients with high BP to a target SBP below 130 mmHg and a target diastolic BP (DBP) below 80 mmHg using standardized office BP measurement.

Use a dihydropyridine calcium channel blocker (CCB) or an ARB as the first-line antihypentensive agent in adult kidney transplant recipients.

Pediatric CKD

In children with CKD, lowering the 24-hour mean arterial pressure (MAP) by ABPM to a target up to and including the 50th percentile for their age, sex, and height is suggested.

For more information, please go to Hypertension, Pediatric Hypertension, Chronic Kidney Disease, and Chronic Kidney Disease in Children.


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