Kidney Case Conference:
How I Treat
Blood Pressure Management in the Patient with
Chronic Kidney Disease
Paul Muntner,1 William C. Cushman,2 and Edgar V. Lerma
CJASN 17: 308–310, 2022. doi: https://doi.org/10.2215/CJN.13040921
Introduction
The Kidney Disease Improving Global Outcomes
(KDIGO) 2021 Clinical Practice Guideline on the Man-
agement of Blood Pressure in Chronic Kidney Disease
includes new recommendations on BP management
for individuals with CKD not receiving dialysis. Two
important topics discussed are the importance of stan-
dardized office BP measurement and the evidence-
based BP target.
Patient Presentation
A 65-year-old man was referred for management of
hypertension. Initial routine laboratory tests showed a
serum creatinine of 2.0 mg/dl, corresponding to an
eGFR of 34 ml/min per 1.73 m2. After a standardized
measurement protocol, his mean office systolic BP
was 140 mm Hg and diastolic BP was 90 mm Hg. He
used a wrist BP device at home and reported a systolic
BP of 130–140 mm Hg and a diastolic BP of 90–100
mm Hg. He was taking amlodipine 5 mg, chlorthali-
done 25 mg, and benazepril 20 mg daily. He had a uri-
nalysis showing 21 proteinuria on dipstick, which
was confirmed on repeat testing. His primary care
provider expressed concern about being too aggres-
sive in lowering BP as the patient appeared frail and
had CKD.
Standardized Office BP Measurement
The KDIGO 2021 BP guideline emphasizes the
importance of measuring BP utilizing a standardized
approach, consistent with those in large outcome tri-
als (1). The term “standardized” means following a
protocol that includes the setting where BP is mea-
sured, patient preparation, positioning, not talking
during a rest period or measurements, and the mea-
surement of BP itself (Figure 1). Consistent with
other BP guidelines, the KDIGO guideline recom-
mends the management of BP be on the basis of mul-
tiple measurements taken in the office on more than
a single occasion. Not following a protocol (i.e., non-
standardized BP measurements) will yield BP levels
that often do not reflect a patient’s regular BP level.
308 Copyright © 2022 by the American Society of Nephrology
3
1
Department of
Epidemiology,
There is no substitute for standardized BP levels University of Alabama
because nonstandardized BP levels cannot be con- at Birmingham,
Birmingham, Alabama
verted to standardized levels. 2
Department of
The use of an automated oscillometric BP device, as Preventive Medicine,
opposed to a manual device, to measure office BP has University of Tennessee
several advantages. Automated oscillometric BP devices Health Science Center,
Memphis, Tennessee
can be programmed to take multiple BP measurements 3
Section of Nephrology,
after a prespecified rest period. Similarly, BP measured University of Illinois at
with these devices can be taken unattended, without a Chicago College of
health care provider in the room, preventing the patient Medicine/ Advocate
Christ Medical Center,
and provider from talking during the procedure. Man- Oak Lawn, Illinois
ual devices, especially aneroid manometers, need to be
calibrated frequently, but usually are not, and digit Correspondence:
preference is common with manual measurements. Dr. Edgar V.
Even in patients with atrial fibrillation, automated oscil- Lerma, University of
Illinois at Chicago
lometric BP devices provide reasonably accurate sys-
College of Medicine/
tolic BP readings. Advocate Christ
Out-of-office BP measurements with ambulatory BP Medical Center, 4440
monitoring or home BP monitoring are recommended W 95th Street Oak
to complement standardized office BP readings for the Lawn, IL 60453. Email:
nephron0@gmail.com
management of high BP. When recommending home
BP monitoring, patients should use the standardized
approach for measurement with a device that measures
brachial artery BP and has been validated.
BP Targets
For patients with high BP and CKD who are not
receiving dialysis, a target systolic BP ,120 mm Hg is
recommended. This recommendation is primarily on
the basis of a single high-quality randomized controlled
trial, the Systolic Blood Pressure Intervention Trial
(SPRINT), which demonstrated that “targeting systolic
BP to ,120 mm Hg, when measured under standard-
ized conditions” reduces cardiovascular events and
mortality in patients with CKD by 25%–30% (2).
Lifestyle interventions including reduction of die-
tary sodium intake and increase in moderate-intensity
physical activity are the initial recommendations for
the management of elevated BP and hypertension.
When pharmacologic therapy is indicated, lifestyle
interventions should be continued. Renin-angiotensin-
system inhibitors are recommended for people with
high BP, CKD, and moderately or severely increased
www.cjasn.org Vol 17 February, 2022
CJASN 17: 308–310, February, 2022 Blood Pressure Management, Muntner et al. 309

No talking during rest period

and between measurements
Cuff to fit arm size
(small, medium, large, extra-large)
Arm bare and resting.
Mid-arm at midpoint of the sternum

Back supported

Validated oscillometric or manual

• Quiet room (no talking by
patient or observer)
auscultatory device, calibrated
• No smoking, caffeine, or periodically
exercise for t 30 min before
measurement Feet flat on floor
• Empty bladder
• Relax for > 5 min

Lifestyle
Sodium intake < 2 g/d (< 90 mmol/d)
•
• Physical activity: 150 min/week moderate-intensity

Adults with CKD with and without diabetes

Systolic BP <120
Targets mm Hg

ACEi or ARB
Preferred drugs G1–G4, A3 without diabetes (1B)
•
G1–G4, A2 without diabetes (2C)
•
• G1–G4, A2 or A3 with diabetes (1B)

Pros Uncertain Cons

p Mortality Long-term n AKI and electrolyte
p CV events kidney function abnormalities
n Polypharmacy
n Health care utilization

Figure 1. | Standardized BP measurement protocols, lifestyle, BP targets, and antihypertensive agents. ACEi, angiotensin-converting
enzyme inhibitor; ARB, angiotensin II receptor blocker; CV, cardiovascular.

albuminuria, and may be reasonable for those without
albuminuria (Figure 1).
The cardiovascular and mortality risk-reduction benefits
of a systolic BP goal of ,120 mm Hg for patients with CKD
should be weighed against the risk of potential adverse
events. Although concerns have been raised that intensive
systolic BP lowering leads to syncope, hypotension, electro-
lyte abnormalities, and AKI (Figure 1), this is not supported
by data from randomized trials (2,3). In SPRINT, there was
no evidence of a clinically important difference in hypoten-
sion, syncope, and bradycardia between participants with
CKD randomized to a systolic BP target ,120 mm Hg ver-
sus ,140 mm Hg (2). Although those randomized to a sys-
tolic BP target ,120 mm Hg were more likely to develop
AKI, the overall risk was low (3% per year versus 2% per
year among those randomized to a systolic BP target ,140
mm Hg) and it tended to resolve without any recognizable
long-term adverse effects. Also, an acute/persistent
decrease in eGFR with intensive BP lowering is likely due
to reversible hemodynamic changes. Intensive BP lowering
generally requires more medications, which can contribute
to low adherence and higher health care utilization, such as
more frequent health care provider visits for medication
titration. Adherence can be monitored through standard-
ized questionnaires, and fixed-dose combination medica-
tions can be used because they can lead to better adherence
and faster achievement of BP goals.
There is no recommended target diastolic BP value in
patients with CKD because few trials have compared
intensive versus standard diastolic BP lowering. Recog-
nizing that a wide pulse pressure is common in patients
with CKD, one can extrapolate that targeting a systolic
BP ,120 mm Hg will likely lead to a diastolic BP ,70
mm Hg.
310 CJASN
There are possible exceptions to the recommended target
systolic BP ,120 mm Hg. These are scenarios whereby the
evidence is uncertain for the benefits of intensive BP lower-
ing outweighing the harms. These include patients with
lower eGFR (CKD G4 and G5), diabetes, baseline systolic
BP 120–129 mm Hg (4), etiology of CKD (5), proteinuria,
extremes of age (6), very frail or nursing home residents,
“white-coat” hypertension, and severe hypertension.
Frailty, which is more common among adults with ver-
sus without CKD, is a risk factor for falls, hospitalization,
nursing home placement, and death. There is no evidence
that intensive systolic BP lowering leads to, or worsens,
frailty. In SPRINT, a higher frailty index was associated
with a higher risk for self-reported and injurious falls and
hospitalization (7). However, a systolic BP target of ,120
mm Hg versus ,140 mm Hg resulted in lower rates of car-
diovascular disease and death among frail and not frail
participants. These data suggest frailty should not be a bar-
rier for intensive systolic BP lowering.
It should be noted, however, that not all guidelines rec-
ommend a target systolic BP of ,120 mm Hg. For example,
the American College of Cardiology/American Heart
Association BP guideline recommends a target systolic BP
,130 mm Hg for individuals with CKD not receiving
dialysis (8).
The KDIGO guideline supports the common dictum that
“individualization is key.” For instance, for those with very
limited life expectancy or symptomatic postural hypoten-
sion, a higher systolic BP reading may be appropriate. An
approach of shared decision making between health care
providers and patients should be followed.
Patient Follow-Up
The patient was advised to check his BP on his upper
arm at home using an oscillometric BP device, two times in
the morning and two times in the evening for 1 week. In
addition, while advising him to continue adherence to life-
style modifications, benazepril was increased to 40 mg and
amlodipine to 10 mg daily in a single-pill combination,
along with chlorthalidone 25 mg daily. In a recent random-
ized trial including adults with an eGFR of 15 to ,30 ml/
min per 1.73 m2, chlorthalidone titrated up to 50 mg versus
placebo lowered systolic BP by 10.5 mm Hg over 12 weeks
(9). During a follow-up visit, his BP was recorded at
115/70 mm Hg. He remained asymptomatic and his
laboratory studies were unremarkable.
Disclosures
E.V. Lerma reports having employment with Associates in
Nephrology; reports having consultancy agreements with Akebia,
Bayer, Otsuka, Travere Therapeutics, and Vifor; ownership interest
in Fresenius Joint Venture; receiving royalty/ honoraria from
Elsevier, McGraw-Hill, Springer, UpToDate, and Wolters Kluwer;
serving as editorial board member of American Journal of Kidney
Diseases, ASN Kidney News, International Urology and Nephrology,
Journal of Clinical Lipidology, Journal of Vascular Access, Peritoneal
Dialysis International, Prescribers Letter, Renal and Urology News, and
Reviews in Endocrinology and Metabolic Disorders; serving as a Visual
Abstract Editor for CJASN, Kidney 360, and Peritoneal Dialysis Inter-
national; speakers bureau for AstraZeneca, Bayer, Otsuka, and
Vifor; and KDIGO Knowledge Translation Lead. P. Muntner
reports having consultancy agreements with Amgen Inc. and
reports receiving research funding from Amgen Inc. W.C. Cush-
man reports receiving research funding from Eli Lilly and ReCor.
Funding
None.
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