General Nephrology - Target Blood Pressure

Guideline Organization

Recommendation (Evidence Level)

Evidence

Comments

CARI-Australia

Prevention of Progression of CKD
2006

Guidelines (Level I/II Evidence):
 - Lower systolic blood pressure (SBP) minimizes the risk of progression to end-stage kidney disease (ESKD), especially with proteinuria. (Level II evidence)
 - A target blood pressure (BP) of < 125/75 mmHg (or mean BP < 92 mmHg) if proteinuria > 1gm/24 hours, may be beneficial. (Level II evidence)
 - A target BP of < 130/80 mmHg (or mean BP < 97 mmHg) if proteinuria is
0.25 – 1g/24 h, may be beneficial. (Level II evidence)
 - Target BP should be < 130/85 mmHg (or mean BP < 100 mmHg) if
proteinuria < 0.25 g/24 hours. (Level II evidence) However, there may be
other potential benefits of achieving lower BP than a mean of 100 mmHg with respect to reduced cardiovascular risk.
 - There is no evidence concerning Target BP for paediatric patients with progressive kidney disease.

Suggestions for Clinical Care (level III and IV evidence)
 - There is evidence for a lower BP target with greater degrees of proteinuria (> 1 g/day). A precise goal below 130/80 mmHg is not clear. These patients should be carefully monitored.

Blood pressure control: targets

Guidelines (Level I/II Evidence):
- Adequate control of blood pressure (BP) slows progression in diabetic nephropathy. (Level I evidence)
 - Goal blood pressures in diabetic nephropathy should be < 130/85 mmHg
in patients over 50 years of age and < 120/70–75 mmHg for those under 50 years.* (Level I evidence) Multiple antihypertensives are usually required to achieve target BP.
 - Protection against both nephropathy progression and cardiovascular events is provided by good BP.

Suggestions for Clinical Care (level III and IV evidence)
 - Effective BP control is the single most important factor in limiting rate of progression of diabetic nephropathy.
 - Most hypertensive diabetic patients will require treatment with two or more
antihypertensives to achieve optimal BP control.
 - The recommendation of target BP to vary with age is based on clinical caution in a population at risk of cerebrovascular disease, rather than any evidence for a J-curve effect in the diabetic population.
 - Elderly patients with Type 2 diabetes commonly have high systolic blood pressure (SBP) and pulse pressure, but normal diastolic pressure. Therapy in this group needs to target SBP.

Antihypertensive therapy in diabetic nephropathy

CSN-Canada

EBPG-Europe

EBPG endorsed the 2004 KDOQI hypertension guidelines (see below).

KDOQI-US

Hypertension and Antihypertensive Agents in Chronic Kidney Disease
(2004)

 - Target BP for CVD risk reduction in CKD < 130/80 mm Hg (except orthostatic hypotension, postprandial hypotension, autonomic dysfunction and severe peripheral vascular disease).  (Level B)

Hypertension and antihypertensive agents in chronic kidney disease.
Guideline 7. Pharmacological therapy:  Use of antihypertensive agents in CKD patients

 - Target BP in diabetic kidney disease < 130/80 mm Hg.

Guideline 8. Pharmacological therapy:  diabetic kidney disease

 - Target BP in nondiabetic kidney disease < 130/80 mm Hg.

Guideline 9. Pharmacological therapy:  nondiabetic kidney disease

UK-Renal Association

Module 1: CKD
2007

 - Amongst patients with CKD blood pressure should be lowered to <130/80mmHg (evidence)

CKD - Section 2: Treatment of Patients with CKD