NEW YORK (Reuters Health) – Updated advice on managing blood pressure in patients with chronic kidney disease (CKD) not receiving dialysis recommends targeting systolic BP to less than 120 mm Hg measured by a standardized technique in the office.
This target was adopted based on the demonstrated “benefits of intensive BP control on cardiovascular and all-cause mortality. The effects of intensive BP control on the risk for progressive CKD are much less certain,” the writing group says in a guideline synopsis published in Annals of Internal Medicine.
The guideline recognizes that there are certain CKD subgroups where the evidence to support the systolic BP target of less than 120 mm Hg is “less well developed, and hence the risk-benefit tradeoffs are less certain. These include persons with diabetes, advanced CKD (stage G4 or G5), proteinuria greater than 1 g/d, extremes of age, white coat hypertension, or very low diastolic BP. Additional RCTs are needed in these subpopulations.”
The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline includes 11 detailed recommendations and 20 practice points and updates the group’s 2012 guideline on this topic.
The update emphasizes that “routine” or “casual” office BP measurement – which refers to measurements obtained without standard preparations and measurement techniques – should no longer be routine in clinical practice.
Instead, standardized BP measurement that follows proper patient preparation and technique, aligns with clinical trial measurement procedures and is advocated by the American Heart Association, is advised.
“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. Automated office BP, either attended or unattended, may be the preferred method of standardized office BP measurement,” the guideline states.
It suggests out-of-office BP measurements with ambulatory BP measurement or home BP monitoring be used to complement standardized office BP readings for the management of high BP.
In terms of diet and lifestyle recommendations, a target sodium intake of less than 2 g sodium per day (or <90 mmol of sodium per day, or < 5 g of sodium chloride per day) is recommended in patients with high BP and CKD. These patients should also be advised to get at least 150 minutes per week of moderate-intensity physical activity, or to level compatible with their cardiovascular and physical tolerance.
Drug therapy recommendations include starting renin-angiotensin-system inhibitor (RASI) therapy – angiotensin-converting-enzyme inhibitors (ACEIs) and angiotensin II-receptor blockers (ARBs) – for people with high BP, CKD, and moderately to severely increased albuminuria with or without diabetes.
Any combination of ACEI, ARB and direct renin-inhibitor therapy in patients with CKD with or without diabetes should be avoided.
“Overall, although some debate about optimal BP targets will likely continue, the 2021 KDIGO recommendations generally align with many recent recommendations that advocate wide implementation of standardized office BP measurement and treatment that aims to normalize BP,” write the authors of a linked editorial in Annals of Internal Medicine.
Dr. George Thomas and Dr. Crystal Gadegbeku of Glickman Urological and Kidney Institute at Cleveland Clinic, in Ohio, note, “Further research is needed to guide clinical approaches to successfully achieve and maintain the lower BP targets, enhance patient engagement, and develop a health system that facilitates BP management care coordination among internists and nephrologists in patients with CKD.”
“Patients with CKD constitute one of several high-risk populations that receive proven cardiovascular benefit from more intensive BP therapy. Thus, the potential benefits of all clinicians implementing the KDIGO practice standards are substantial,” they conclude.
SOURCE: https://bit.ly/3qhkt56 and https://bit.ly/3gTe0Js Annals of Internal Medicine, online June 21, 2021.