High blood pressure can worsen the condition in CKD patients. The key recommendations from the clinical practice guidelines for the management of blood pressure in CKD are elucidated in this article.

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The 2021 Clinical Practice Guideline for the Management of Blood Pressure (BP) in Chronic Kidney Disease (CKD) includes updates on BP management in non-dialysis CKD and strategies to control BP to reduce cardiovascular disease risk.

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Key recommendations

Below we enumerate the main recommendations from the guidelines.

1. Blood pressure measurement

Standardised office BP measurement

Standardised office BP measurement is recommended in preference to routine office BP for the management of high BP in adults. Standardised office BP is defined as BP measurements made using recommended preparations and measurement techniques, regardless of the type of equipment used. The guidelines include a checklist for standardised office BP measurement.

Out-of-office BP measurements

Out-of-office BP measurements can complement standardised office BP measurements for the management of high BP. Out-of-office BP measurements are found to be strongly associated with cardiovascular and kidney outcomes in both the general population and CKD population. Home BP monitoring is preferred to 24-hour ambulatory BP monitoring (ABPM) as visiting the clinic is not always practical.

2. Lifestyle interventions for lowering blood pressure in patients with CKD not receiving dialysis

Reductions in dietary salt intake

CKD patients with high BP should not consume more than 2 g (or <90 mmol) of sodium per day.

Reducing the intake of dietary salt intake can lead to short-term reductions in BP which may lower the need for antihypertensive medications. In children with CKD, the <2 g (<90 mmol) daily target should be adjusted for body weight.

Reductions in salt intake may be inappropriate or followed with caution in the following cases:

1. Patients with CKD and salt-wasting nephropathy.

2. Patients who follow the Dietary Approaches to Stop Hypertension (DASH) diet and use salt substitutes. These approaches may increase the risk of hyperkalemia in patients with CKD.

Physical activity

3. Blood pressure management in patients with CKD, with or without diabetes, not receiving dialysis

Target systolic blood pressure:  

Adults with high BP and CKD should be treated to a target systolic blood pressure (SBP) of <120 mm Hg, as determined by standardised office measurement if tolerated. This recommendation should not be used for patients with a kidney transplant or those receiving dialysis.

The SBP target is selected based on the cardioprotective, survival, and potential cognitive benefits demonstrated in the SPRINT trial. BP targets should however be individualised considering the patient’s characteristics, tolerability, and preferences.

Antihypertensive drugs:

There is a lack of data on the use of specific antihypertensive agents to treat high BP in CKD. The guidelines suggest treating people with CKD and BP who are at least 20 mm Hg above the target with combinations of 2 or more antihypertensive drugs.

The following are the key recommendations for the use of antihypertensive drugs in CKD patients:

1. Renin-angiotensin-system inhibitors (RASi) (angiotensin-converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB]) are recommended for people with high BP, CKD, and severely increased albuminuria (G1–G4, A3) without diabetes.
2. RASi (ACEi or ARB) is suggested for people with high BP, CKD, and moderately increased albuminuria (G1–G4, A2) without diabetes.
3. RASi (ACEi or ARB) is recommended for people with high BP, CKD, and moderately to severely increased albuminuria (G1–G4, A2 and A3) with diabetes.
4. Any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy should be avoided in patients with CKD, with or without diabetes.

4. Blood pressure management in kidney transplant recipients (CKD G1T–G5T)

BP targets

Adult kidney transplant recipients with high BP should be treated to a target BP of <130/80 mm Hg using standardised office BP measurement.

Choice of antihypertensive agents

Dihydropyridine CCB or an ARB should be used as the first-line antihypertensive agent. The use of dihydropyridine CCBs or ARBs is associated with a reduction in graft loss.

Individual patient characteristics should be assessed before prescribing treatment:

1. In kidney transplant recipients with proteinuria, ARBs should be considered first, due to the antiproteinuric effects of these medications.
2. For patients in the early post-transplant period, ARBs should be avoided until kidney transplant function has stabilised. This is because the acute negative effect of ARB on GFR can be confused with other causes of graft dysfunction such as rejection.
3. ARBs are contraindicated in women trying to conceive or who are pregnant. CCB should be used during pregnancy and lactation.

5. Blood pressure management in children with CKD

In children with CKD, 24-hour mean arterial BP (MAP) measured using ABPM should be lowered to one that is at ≤50th percentile of normal children with corresponding age, sex, and height.

For treating high BP in children with CKD, the guidelines suggest a practice point for the use of an ACEi or ARB as first-line therapy. ACEi or ARB lower proteinuria and are usually well-tolerated.

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