In this post, I link to and excerpt from KDIGO 2021 Clinical Practice Guideline for the
Management of Blood Pressure in Chronic Kidney Disease [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Kidney Int. 2021 Mar;99(3S):S1-S87.
All that follows is from the above resource.
KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease
S3 Tables, figures, and supplementary material
S7 KDIGO Executive Committee
S8 Reference keys
S9 CKD nomenclature
S10 Conversion factors and Glossary of terms for blood pressure management
S11 Abbreviations and acronyms
S14 Updates to the KDIGO guideline format
S18 Work Group membership
S23 Summary of recommendation statements and practice points
S26 Chapter 1: Blood pressure measurement
S32 Chapter 2: Lifestyle interventions for lowering blood pressure in patients with
CKD not receiving dialysis
S37 Chapter 3: Blood pressure management in patients with CKD, with or without
diabetes, not receiving dialysis
S55 Chapter 4: Blood pressure management in kidney transplant recipients (CKD
S59 Chapter 5: Blood pressure management in children with CKD
S62 Methods for guideline development
S71 Biographic and disclosure information
The development and publication of this guideline were supported by KDIGO. The opinions or views expressed in this
professional education supplement are those of the authors and do not necessarily reflect the opinions or recommendations of
the International Society of Nephrology or Elsevier. Dosages, indications, and methods of use for products that are referred to
in the supplement by the authors may reflect their clinical experience or may be derived from the professional literature or
other clinical sources. Because of the differences between in vitro and in vivo systems and between laboratory animal models
and clinical data in humans, in vitro and animal data may not necessarily correlate with clinical results.
Abbreviations and acronyms
ABPM ambulatory blood pressure monitoring
ACEi angiotensin-converting enzyme inhibitor(s)
ACR albumin-creatinine ratio
AOBP automated office blood pressure
AKI acute kidney injury
ARB angiotensin II receptor blocker
BP blood pressure
CCB calcium channel blocker
CI confidence interval
CKD chronic kidney disease
DBP diastolic blood pressure
DRI direct renin inhibitor
eGFR estimated glomerular filtration rate
ERT Evidence Review Team
ESKD end-stage kidney disease
GFR glomerular filtration rate
GRADE Grading of Recommendations Assessment,
Development, and Evaluation
HBPM home blood pressure monitoring
HF heart failure
HR hazard ratio
KDIGO Kidney Disease: Improving Global Outcomes
MACE major adverse cardiovascular events
MAP mean arterial pressure
MI myocardial infarction
MRA mineralocorticoid receptor antagonist
NSAID nonsteroidal anti-inflammatory drug(s)
OR odds ratio
PCR protein-creatinine ratio
RAS renin-angiotensin system
RASi renin-angiotensin system inhibitor(s)
RCT randomized controlled trial
RR relative risk
SBP systolic blood pressure
SGLT2 sodium-glucose cotransporter-2
T1D type 1 diabetes
T2D type 2 diabetes
UKPDS United Kingdom Prospective Diabetes Study
The Work Group has identified 2 major areas that warrant particular attention in this guideline update because of new evidence and interests that have emerged since the publication of the original guideline. These 2 areas are: (i) BP measurement (Chapter 1) and (ii) BP targets within the domain of BP management in CKD patients not receiving dialysis (Chapter 3). These 2 issues are closely related as the systolic BP (SBP) target of <120 mm Hg recommended in Chapter 3 is contingent upon proper BP measurement technique following recommended rigorous procedures.
This lower SBP target is largely based on its cardioprotective, survival, and potential cognitive benefits. There are no new data supporting the renoprotective benefits of targeting SBP <120 mm Hg. The overall evidence for kidney protection at this low SBP level is almost non-existent, but it is somewhat more convincing for CKD patients with proteinuria and long-term follow-up.
There are certain subpopulations in CKD in which the evidence supporting the SBP target of <120 mm Hg is less rigorous; hence, the risk–benefit ratios in those instances are less certain. These subpopulations include those with diabetes, advanced CKD (G4 and G5), significant proteinuria, very low diastolic blood pressure (DBP), “white-coat” hypertension, and at extreme ages (younger or older). Thus, randomized controlled trials (RCTs) in these subpopulations are necessary.
The term “high BP” is used throughout the document to denote BP above the target. For most patients with CKD not receiving dialysis, the target is SBP <120 mm Hg. For kidney transplant recipients (Chapter 4), the target SBP is <130 mm Hg, and target diastolic BP (DBP) is <80 mm Hg. For children with CKD (Chapter 5), a mean arterial pressure (MAP, calculated as DBP + 1/3 x pulse pressure) ≤50th percentile for age, sex, and height is the primary target
Summary of recommendation statements and practice
The term “high BP” is used throughout the document to denote BP above the target for a particular population under
consideration. For most adult patients with CKD not receiving dialysis, the target is SBP <120 mm Hg (Chapter 3). For adult
kidney transplant recipients, the target remains SBP <130 mm Hg/DBP <80 mm Hg (Chapter 4). For pediatric populations,
MAP (calculated as DBP + 1/3 x pulse pressure) targets are age-dependent (Chapter 5). Given that these targets vary according
to the subpopulation of interest, we have avoided the term “hypertension” when referring to treatment decisions, as the term “hypertension” requires a single numerical definition and does not necessarily facilitate BP management.
summary of recommendation statements and practice points www.kidney-international.org
Chapter 1: Blood pressure measurement
Recommendation 1.1: We recommend standardized office BP measurement in preference to routine office BP measurement for the management of high BP in adults (1B).
Practice Point 1.1: An oscillometric BP device may be preferable to a manual BP device for standardized office BP
measurement; however, standardization emphasizes adequate preparations for BP measurement, not the type of equipment.
Practice Point 1.2: Automated office BP (AOBP), either attended or unattended, may be the preferred method of standardized office BP measurement.
Practice Point 1.3: Oscillometric devices can be used to measure BP among patients with atrial fibrillation.
Recommendation 1.2: We suggest that out-of-office BP measurements with ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) be used to complement standardized office BP readings for the management of high BP (2B).
Chapter 2: Lifestyle interventions for lowering blood pressure in patients with CKD not receiving dialysis
2.1. Sodium intake
Recommendation 2.1.1: We suggest targeting a sodium intake <2 g of sodium per day (or <90 mmol of sodium
per day, or <5 g of sodium chloride per day) in patients with high BP and CKD (2C).
Practice Point 2.1.1: Dietary sodium restriction is usually not appropriate for patients with sodium-wasting nephropathy.
Practice Point 2.1.2: The Dietary Approaches to Stop Hypertension (DASH)–type diet or use of salt substitutes that are rich in potassium may not be appropriate for patients with advanced CKD or those with hyporeninemic hypoaldosteronism or other causes of impaired potassium excretion because of the potential for hyperkalemia.
2.2. Physical activity
Recommendation 2.2.1: We suggest that patients with high BP and CKD be advised to undertake moderate- intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with their cardiovascular and physical tolerance (2C).
Practice Point 2.2.1: Consider the cardiorespiratory fitness status, physical limitations, cognitive function, and risk of falls
when deciding on the implementation and intensity of physical activity interventions in individual patients.
Practice Point 2.2.2: The form and intensity of physical activity should be considered and modified as necessary in individual patients. There may still be important health benefits even if physical activity falls below targets proposed for the general population.
Chapter 3: Blood pressure management in patients with CKD, with or without diabetes, not receiving dialysis
3.1. Blood pressure targets
Recommendation 3.1.1: We suggest that adults with high BP and CKD be treated with a target systolic blood pressure (SBP) of <120 mm Hg, when tolerated, using standardized office BP measurement (2B).
Practice Point 3.1.1: It is potentially hazardous to apply the recommended SBP target of <120 mm Hg to BP measurements obtained in a non-standardized manner.
Practice Point 3.1.2: Clinicians can reasonably offer less intensive BP-lowering therapy in patients with very limited life
expectancy or symptomatic postural hypotension.
3.2 Treatment with antihypertensive drugs, including RAS inhibitors (RASi)
Recommendation 3.2.1: We recommend starting renin-angiotensin-system inhibitors (RASi) (angiotensin-converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB]) for people with high BP, CKD, and severely increased albuminuria (G1–G4, A3) without diabetes (1B).
Recommendation 3.2.2: We suggest starting RASi (ACEi or ARB) for people with high BP, CKD, and moderately increased albuminuria (G1–G4, A2) without diabetes (2C).
Recommendation 3.2.3: We recommend starting RASi (ACEi or ARB) for people with high BP, CKD, and moderately-to-severely increased albuminuria (G1–G4, A2 and A3) with diabetes (1B).
Practice Point 3.2.1: It may be reasonable to treat people with high BP, CKD, and no albuminuria, with or without diabetes, with RASi (ACEi or ARB).
Practice Point 3.2.2: RASi (ACEi or ARB) should be administered using the highest approved dose that is tolerated to achieve the benefits described because the proven benefits were achieved in trials using these doses.
Practice Point 3.2.3: Changes in BP, serum creatinine, and serum potassium should be checked within 2-4 weeks of
initiation or increase in the dose of a RASi, depending on the current GFR and serum potassium.
Practice Point 3.2.4: Hyperkalemia associated with use of RASi can often be managed by measures to reduce the serum
potassium levels rather than decreasing the dose or stopping RASi.
Practice Point 3.2.5: Continue ACEi or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks
following initiation of treatment or an increase in dose.
Practice Point 3.2.6: Consider reducing the dose or discontinuing ACEi or ARB in the setting of either symptomatic
hypotension or uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms while treating kidney failure (estimated glomerular filtration rate [eGFR] <15 ml/min per 1.73 m2).
Practice Point 3.2.7: Mineralocorticoid receptor antagonists are effective for management of refractory hypertension but may cause hyperkalemia or a reversible decline in kidney function, particularly among patients with
3.3. Role of dual therapy with RASi
Recommendation 3.3.1: We recommend avoiding any combination of ACEi, ARB, and direct renin inhibitor
(DRI) therapy in patients with CKD, with or without diabetes (1B).
Chapter 4: Blood pressure management in kidney transplant recipients (CKD G1T–G5T)
Practice Point 4.1: Treat adult kidney transplant recipients with high BP to a target BP of <130 mm Hg systolic and <80
mm Hg diastolic using standardized office BP measurement (see Recommendation 1.1).
Recommendation 4.1: We recommend that a dihydropyridine calcium channel blocker (CCB) or an ARB be used as the first-line antihypertensive agent in adult kidney transplant recipients (1C).
Chapter 5: Blood pressure management in children with CKD
Recommendation 5.1: We suggest that in children with CKD, 24-hour mean arterial pressure (MAP) by ABPM should be lowered to ≤50th percentile for age, sex, and height (2C).
Practice Point 5.1: We suggest monitoring BP once a year with ABPM, and monitoring every 3–6 months with standardized auscultatory office BP in children with CKD.
Practice Point 5.2: In children with high BP and CKD, when ABPM is not available, manual auscultatory office BP obtained
in a protocol-driven standardized setting targeting achieved SBP <90th percentile for age, sex, and height of normal children is a reasonable approach.
Practice Point 5.3: Use ACEi or ARB as first-line therapy for high BP in children with CKD. These drugs lower proteinuria
and are usually well tolerated, but they carry the risk of hyperkalemia and have adverse fetal risks for pregnant women.
Throughout this chapter, standardized office BP refers to
measurements obtained according to recommended preparation procedures (Figure 2), regardless of the type of equipment used. In contrast, routine office BP refers to measurements obtained without following these recommended preparation procedures and is often also called casual
An oscillometric BP device may be preferable to a manual BP device for standardized office BP measurement (see Practice Point 1.1.), but the main emphasis is on the importance of measuring BP according to recommended preparation procedures (Figure 2).
In the judgment of the Work Group, the potential benefits of additional information obtained from out-of-office BP measurements outweigh the additional costs and increased patient burden that these measurements impose. We suggest using an initial ABPM to supplement standardized office BP and HBPM for ongoing management of BP. Although ABPM may be the better measurement method, HBPM is more practical for routine out-of-office assessment.