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    Hta

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    Elena Stepan

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    OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF NEPHROLOGY Ty I Ss N Nes SUPPLEMENT TO kidney INTERNATIONAL KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease VOLUME 99 | ISSUE 3S | MARCH 2021 wor kidney international.org kidney INTERNATIONAL EDITOR Piere Ronco, Pais Cinicalimestgaton DEPUTY EDITOR Brad Rovin, Cokimius Tansotenal Neprobgy PAST EDITORS Delle Schindort, Now Yor (ais Ab-Avgat New York Saul Kahr Louis ‘Thomas. Andeeot Lite Rock Roscoe R. Robinson, Durtam EDITORIAL BOARD ‘Anupam Agarwal Benioghan Even Azelogh, New York, ‘Sean Barbour, Vancower ‘Jonathan Barratt, Leicester David Basle Indenapols John Beam, Clayton Peter Boor, Aachen Frank Bridous, Fortes ‘ke Campbell New York Daniel Cattran, Toento Christos Chatiantoniou, Paris Yepuchen, Beieg Philip Clayton, Acie Steven Coca, New York Terence Cook, London VivetteD/Agat New York Farhad Danesh, chica00 Joh Daugirdas, chicago [Andrew Davenport, London ‘Mare De Bro, Anivesp Vikas Dharnidhara, St Luis Kent Dot Tyo Be Dong, Beijing Zheng Dong, Augista ak Uwe Eckard, Bern Somchai Eiam-Ong, Songkick Michael Emmett, Dalis Roger Evans Mourne Pete Evenepoet Leuven Robert Fairchild, Cleveland Sarah Faubel, Denver (Cristian Fal, mingham Femando Fervenza, Rochester Steven Fshbane, Winco Danilo Flier, Homburg ‘Josephine Forbes, Béstane ‘Aesia Fomont Mam Barry Freedman, Winston Salem ‘Masafumi Fukagawa, shard ‘Amit Garg London, reario Vesna Garovi Rochester Richard Gassod, Laguna Niguel David S. Goat, New York ‘Mark Maas, Los Angcks Volker Haase, Nasvile Jan Halbaiter Let Peter. Haris, Rochester Joh (jing) He New York [NEPHROLOGY DIGEST EDITOR (Charting Wyatt Hew York STATISTICIANS Vic Hasselblad, Jackson ‘heahen Jn, New York ‘Joseph kim, Torco ‘Yesu, Durham Dorothea Ntsc, London Rajasekhar Famalrishnan New York KI FELLOWSHIP INTERNS ‘Anna Francs Brisbane ‘Sethu Madhavan, Columbur Michelle Hladunewieh Toronto Fan Fan Hou, Guangzhou Pascal Houllier, Pars (Che yuan Hsu, San Francisco “Tobies 8 Huber, Hamburg ‘Benjamin Humphreys, St Lous Reiko Inagl,TaKyo enar Shaver, rest Neck Jaap Jes, recht Kamyar Kalantar Zadeh, Orange Roberto Kali, bua Cty Frederik Kase, New York Krzysztof Kiya, New York ‘A Richar Kitching, Cayton ‘Anna Keetgen, Frew, Jeffrey Kopp, Bethesco ‘Mathias Kretaler, Ann Abor ‘Guistophe Legendre, Pars Kevin Lemley, Los Angeles Emmanuel Letaverir, aris ‘Adeera Levin, Vanceuver Philip 7. Li, Hong Kong a Le, Toronto Melissa ite Brisbane Waitin, Port athleen Liu, San Francisco YYouhua Li FtsouTh ‘Alexandre Loupy, Pars ‘Cuistopher Lu Callas Friedrich Luft, sin Johannes Mann, Minchen Peter). Margetts Hamfton ‘Glen Markouate, New York Ziad Massy, Parts Kniire Matsushita, Batre ‘Mignon McCulloch, Cape Town “Timothy W- Meyer, Pao Ato Aman Mim, Tokyo Jetrey Miner, St Luis (Marcus Moe, Aachen Jeremiah Mornssey, St. Lous ‘Rosa Mos, So Foul David Nikole Paterson, Cayton ‘Marina Nors, Rania ‘ed Okpechi Cpe Town ASSOCIATE EDITORS Toby Coates, Adie Translator runbogy Olivier Devuyst Zurich Prysilogy,Gonets, Kney Cancer ‘man 8. Drucke, Pare (GD Hypertension Nephron rgen Foege, Aachen “Glomeruonephits CKD MID ‘Agnes B.Foge Noshvile ‘Gime anderen! Rena Potalogy T.Alp her, Nosh Dias Acute Kidney Inu, Nuon, Metobaien ‘Masaomi Nangak, Toi inca ond Experiment CHD cand Diabece Ncnay Disease Jl Radhakrishnan Now Yok aor, Cineal tudes, Images in Nephology, Make Your Diognosts ‘Germaine Weng, Sydney fe Course Fpidemogy Heath Economics cand Onconephralogy Mark Olss, Charotesite ‘an Olver, New York ‘crisianPattaro, olzino [doPeioto, WestHaven ‘Mark Perazela, New Haven Janos Pet-Peterdl Los Angeles ‘Martin Pollak Boston ‘Ambra Pera Nahe ‘Susan Quaggin, Gicaoo W. Brian Reeves San Antonio eather Rech, Tororio| ‘Giuseppe Remuzz, Bergamo Connie Rhee, Onnige ‘Mariana Rodriguez, Cordoba Paola Romagnani Firenze ‘Av Rosenberg, these Michael Ross, New York Robert Safrsten, New Haven ‘Simone Sanna-Cherchl New York Mario Scher, Ekangen Johannes Schlondrt, Boston ‘al Schmidt 01, New Yore ‘Stephan Seger Aarau Kumar Sharma, L3 Jolla "Natale Staph, Oxford atalin Susztak, Philadelphia Yoshio Tera, Narkoku ‘Tetsuro Tanaka, Tokyo Sydney CW. Tang, Hong Kor Ravi Thadhani Boston Plates Tharau, Pars Joshua Thurman Datver dens Tze, Singapore ‘marcello Tonel dmonton Herman Timarchi, Bsns Nes Frank van der Sande, Maastient Marc Verloet, Amsterdam ‘Marina Vivre Rome Carsten Wagner, Zurich ‘Angela Wang, Hong Kong ‘Donald Wesson, Teme Jack Wetzels ijn ‘Adam Whaley Connell Colurbla Keng Thye Woo, Singapore Motoko Yanagi, Kyeto Xueging Yu Guangzhou ‘Sur Yuruke, Toyo won kidney international.org Scope ‘aay bemavionalisdeveted 0 kdney research. als to infor the ‘researcher the cnkalinvestgator ad hepractcng nephlgistonallaspects f Kidney research These Incudethe Lest cna tudes on emerging {developments i nephriogyand the highest level oforgnal esearchstalesin neal ad base Kidney research The journal reflec the fell through ica ‘eviews commentaries xgina articles, remarkable images news features, ‘guidelines, nd problem focused artes fr the dagioss and wretment of ey patents ‘This journais covered by BIOS, Chemical Abstroet, EMBASEExcerpa Medica. 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KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease Publication of this supplement is sponsored by Kidney Disease: Improving Global Outcomes (KDIGO) ‘The opinions or views expressed in this supplement are those of the authors and do not necessarily reflect the opinions or recommendations of the International Society of Nephrology or Elsevier. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and Using any information, methods, compounds or experiments described herein. Because of rapid advances in ‘the medical sciences, in particular, Independent verification of diagnoses and drug dosages should be made. To the fullest extent ofthe law, no responsibility is assumed by Kidney Disease: Improving Global Outcomes (KOIGO), the International Society of Nephrology, or Elsevier for any injury and/or damage to persons oF property as a matter of products lability, negligence or otherwise, or from any use or operation of any ‘methods, products, instructions, or ideas contained in the material herein. 7) ISN Officia Joural ofthe International Society of Nephrology Elsevier nv kidney interational.org contents kidney VOL 99 | ISSUE 3S | MARCH 2021 INTERNATIONAL KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group OPEN KDIGO 2021 CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF BLOOD PRESSURE IN CHRONIC KIDNEY DISEASE ny tematond (021) 9, 51-87 contents rw kidney interational.org VOL 99 | ISSUE 35 | MARCH 2021 KDIGO 2021 Clinical Practice Guideline for the Management of Blood kid ney Pressure in Chronic Kidney Disease INTERNATIONAL $3 Tables, figures, and supplementary material 57 KDIGO Executive Committee SB Reference keys $9 CKD nomenclature S10 Conversion factors and Glossary of terms for blood pressure management S11 Abbreviations and acronyms S12 Notice S13. Foreword S14 Updates to the KDIGO guideline format S18 Work Group membership $20 Abstract, $21 Introduction 823 Summary of recommendation statements and practice points 826 Chapter 1: Blood pressure measurement $32 Chapter 2: Lifestyle interventions for lowering blood pressure in patients with CKD not receiving dialysis lood pressure management it diabetes, not receiving dialysis. lod pressure management in kidney transplant recipients (CKD GiT-cs1) S59 Chapter 5: Blood pressure management in children with CKD. $62 Methods for guideline development S71 Biographic and disclosure information $78 Acknowledgments $79 References $37 Chapter 3: patients with CKD, with or without $55 Chapter 4: 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 Intemational 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 Iitersture 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, i vitro andl animal data may not necessarily correlate with clinical results. 2 ida introrel 2021) 9, 51-87 swe kidney interationa.org contents $63 TABLES Table 1. Hierarchy of outcomes Table 2. Clinical questions and systematic review topics in the PICOM format Table 3. Classification for certainty and quality of the evidence Table 4. GRADE system for grading quality of evidence Table 5. KDIGO nomenclature and description for grading recommendations Table 6. Determinants of the strength of recommendation FIGURES Figure 1. Updates to the KDIGO guideline format Figure 2. Checklist for standardized office blood pressure measurement Figure 3. Blood pressure measurement method and device used in select RCTs and prospective observational studies Figure 4. Blood pressure patterns informed by out-of office blood pressure measurements in addition to standardized office blood pressure measurement ‘SPRINT research treatment algorithm for the intensive group (goal SBP <120 mm Hg) 3. Cardiovascular events in patients with CKD G3~G4, A3 without diabetes CCB versus placebo/no treatment for the outcome of graft loss . Search yield and study flow diagram SUPPLEMENTARY MATERIAL Supplementary File (PDF) Appendix A. Search strategies Table 51, Search strategies for systematic review topics ‘Appendix B. Concurrence with Institute of Medicine (IOM) standards for guideline development Table 52. Guideline development checklist ~ IOM standards for development of trustworthy clinical practice guidelines Table 53. Adapted systematic review reporting standards checklist - OM standards for systematic reviews Appendix C. Data supplement - Summary of findings (SoF) tables cited in the guideline text Table 54. General population studies comparing auscultatory versus oscillometric blood pressure measurement devices Table $5, Adults with CKD without diabetes, low-salt diet versus usual or normat-salt Table 56, Adults with type 1 diabetes and CKD, low-salt diet versus normal-salt diet Table S7. Adults with type 2 diabetes and CKD, low-salt diet versus usual diet Table 58. Adults with diabetes and CKD with moderately increased albuminuria, low-salt diet versus normal- salt diet Table 59, Adults with diabetes and CKD with severely increased albuminuria, low-salt diet versus normal-salt diet ‘Table S10. Adults with CKD, any exercise to improve blood pressure versus control (no exercise/placebo exercise) Table $11. Adults with CKD, low blood pressure target (<120 mm Hg) versus standard blood pressure target Table 512. Adults with CKD and increased proteinuria/albuminuria, low blood pressure target versus standard diastolic blood pressure target Table $13. Adults with CKO, low blood pressure target versus standard blood pressure target Table S14. Adults with CKD without diabetes, low blood pressure target versus standard blood pressure target Table S15. Adults with CKD without diabetes, ACEI versus placebo or standard of care Table $16. Adults with CKD without diabetes, ARB versus placebo or standard of care ‘Table S17. Adults with CKD without diabetes, aldosterone antagonist versus placebo or standard care ny tematond (021) 9, 51-87 s contents rw kidney interational.org Table $18. Adults with CKD without diabetes, beta-blockers versus RASI Table $19. Adults with CKD without diabetes, calcium channel blocker versus placebo Table $20. Adults with CKD without diabetes, direct renin inhibitors versus RAS! Table 521. Adults with diabetes and CKD, ACEi versus placebo or standard care ‘Table $22. Adults with diabetes and CKD, ARB versus placebo or standard care Table $23, Adults with diabetes and CKD, ARB versus ACE: Table 524. Adults with diabetes and CKD, aldosterone antagonists versus placebo or standard care Table 525. Adults with diabetes and CKD, beta-blocker versus ACEi Table 526. Adults with diabetes and CKO, calcium channel blocker versus placebo Table $27. Adults with diabetes and CKD, diuretics + ACEI or ARB versus placebo, standard of care, or no treatment Table 528. Adults with diabetes and CKD, aliskiren versus ACEI or ARB. ‘Table $29. Adults with type 2 diabetes and CKD, aliskiren + ACEI or ARB versus placebo + ACEI or ARB ‘Table $30, Adults with diabetes and CKD, calcium channel blocker versus ACEI or ARB. Table $31. Adults with CKD, dual RASI therapy versus single RASi therapy Table 532. Network meta-analysis of adults with CKD, dual RASi therapy versus single RASi therapy ‘Table $33. Kidney transplant recipients, calcium channel blockers versus placebo or no treatment ‘Table S34, Kidney transplant recipients, ARB versus placebo or no treatment Table $35. Kidney transplant recipients, ACEi versus placebo, no treatment, or non-antihypertensive treatment ‘Table $36. Kidney transplant recipients, alpha-blocker versus placebo or no treatment Table 537. Kidney transplant recipients, beta-blocker versus placebo or no treatment Table $38. Kidney tansplant recipients, mineralocorticold receptor antagonists versus placebo Table 539. Kidney transplant recipients, ACEi or ARB versus placebo, no treatment, or standard of care Table 40. Children with CKD, intensified blood pressure control (MAP 0.22 g/g and PE >0.3 g/d), low MAP target (<92 mm Hg) versus standard MAP target (102-107 mm Hg) ‘Adults with CKD, ACEI versus placebo or standard of care tolic mm Hg) versus standard = Adults with CKD, ARB versus placebo or standard of care . Adults with CKD, aldosterone antagonist versus placebo or standard of care . Adults with CKD, beta-blocker versus placebo or standard of care ‘Adults with CKD, beta-blocker versus RASi - Adults with CKD, calcium channel blockers versus placebo ‘Adults with CKO, calcium channel blockers versus Ri ‘Adults with CKD, direct renin inhibitor versus placebo ‘Adults with CKD, direct renin inhibitor versus RASI ‘Adults with CKO, direct renin inhibitor + ACEI or ARB versus placebo or standard of care ‘Adults with CKO, diuretics versus RASi Older adults with CKD (65-85 years old), high-dose ARB versus calcium channel blocker combined with ARB - Adults with CKD, type 2 diabetes, and moderately increased albuminuria, caldum channel blockers + RAS blockade versus RAS blockade - Adults with CKD and chronic hyperkalemia, potassium binder versus placebo ‘Adults with CKD and chronic hyperkalemia, calcium polystyrene sulphonate (CPS) versus sodium polystyrene sulphonate (SPS) Adults with CKD without diabetes, lower MAP (<92 mm Hg) target versus higher MAP (102-107 mm Hg) target ‘Adults with CKD and proteinuria (>19/24 h for at least 3 months) without diabetes, low blood pressure target (<130/80 mm Hg) versus standard diastolic blood pressure target (<90 mm Hg) ‘Adults with CKD without diabetes, lower blood pressure target (<120 mm Ha) versus standard blood pressure target ‘Adults 275 years of age with CKD without diabetes, lower blood pressure target (120 mm Hg) versus standard blood pressure target ‘Adults with CKD without diabetes, calcium channel blockers versus RAS ‘Adults with diabetes and CKD, ACEi or ARB monotherapy versus dual (ACEI + ARB) therapy ‘Adults with diabetes and CKD, diuretics ++ ACEi or ARB versus ACEI or ARB ‘Adults with diabetes and CKD, diuretics + calcium channel blockers versus ACEi or ARB + calcium channel blockers ‘Adults with diabetes and CKD, diuretics + ACEI or ARB versus ACEI or ARB + calcium channel blockers ‘Adults with diabetes and CKD, diuretics + ACEI or ARB + beta-blockers versus placebo plus standard of care ‘Adults with CKD, type 2 diabetes, and moderately increased albuminuria, calcium channel blocker versus ARB plus diuretics se ss contents rw kidney interational.org ‘Table S86. Adults with CKD, type 2 placebo Table $87. Adults with diabetes and CKD, aliskiren versus ACE! or ARB Table $88. Adults with diabetes, chronic hyperkalemia, and CKD, high-dose potas: potassium binder Table S89. Kidney transplant recipients, low-salt diet versus usual or normal-salt diet Table $90. Kidney transplant recipients, Mediterranean diet versus low-fat diet Table $91. Kidney transplant recipients, any exercise to control blood pressure versus control (no exercise/ placebo exercise) ‘Table S92. Kidney transplant recipients, ACEI versus calcium channel blockers Table $93. Kidney transplant recipients, ARB versus calcium channel blockers Table $94, Kidney transplant recipients, ACEi versus ARB Table 595, Kidney transplant recipients, ACEi + calcium channel blockers versus ACEi alone ‘Table $96. Kidney transplant recipients, ACEI + calcium channel blockers versus calcium channel blockers alone Table $97. Kidney transplant recipients, ACE; -+ ARB versus ACEi alone Table $98. Kidney transplant recipients, ACEi + ARB versus ARB alone ‘Table $99. Kidney transplant recipients, ACEI + ARB versus placebo or no treatment Table $100. Kidney transplant recipients, ACE Table $101. Kidney transplant recipients, ACEI Table $102. Kidney transplant recipients, ARB versus beta-blocker Table $103. Kidney transplant recipients, calcium channel blockers versus beta-blocker Table $104. Kidney transplant recipients, ARB versus direct reni Table $105. Kidney transplant recipients, calcium channel blockers versus thiazide Table $106. Kidney transplant recipients, ACEI or ARB versus placebo, no treatment, or standard of care Table 107. Children with CKD, ACEI versus standard treatment. betes and albuminuria (AER >100 mg/24 h), direct renin inhibitor versus ium binder versus low-dose ss ida introrel 2021) 9, 51-87 snr kideyinternationa.org Michel Jadoul, MD KDIGO Co-Chair Mustafa Arici, MD ‘Tara L. Chang, MD, MS Jennifer E. Flythe, MD, MPH Masafumi Fakagawa, MD, PhD Morgan E. Grams, MD, MPH, PhD Fan Fan Hou, MD, PhD Meg Jardine, MBBS, PhD Markus Ketteles, MD, FERA Magglalena Madero, MD ny tematond (021) 9, 51-87 KDIGO executive committee KDIGO EXECUTIVE COMMITTEE Garabed Eknoyan, MD Norbert Lameire, MD, PhD Founding KDIGO Co-Chairs David C. Wheeler, MD, FRCP Immediate Past Co-Chair Wolfgang C. Winkelmayer, MD, MPH, ScD KDIGO Co-Chair Jolanta Malyseko, MD, PhD Ikechi G. Okpechi, MBBS, FWACP, PhD Rukshana Shroff, MD, FRCPCH, PhD Laura Sols, MD Paul E. Stevens, MB, FRCP Sydney C.W. Tang, MD, PhD, FRCP, FACE, FHKCE, FHKAM Marcello A. Tonelli, MD, SM, MSe, FRCPC Christina M. Wyatt, MD KDIGO staff John Davis, Chief Executive Officer Danielle Green, Executive Director Michael Cheung, Chief Scientific Officer Melissa ‘Thompson, Chief Operating Officer Amy Eadley, Guideline Development Director Kathleen Conn, Director of Communications “Tanya Green, Events Director Coral Cyzewski, Events Coordinator sr reference keys rw kidney interational.org Reference keys NOMENCLATURE AND DESCRIPTION FOR RATING GUIDELINE RECOMMENDATIONS Within each recommendation, the strength of recommendation is indicated as Level 1 or Level 2, and the quality of the supporting evidence is shown as A, B, C, or D. Implications Grade Patients ‘Giniane Paley Level 1 “Strong” ‘Mort people in your stuation would Most patients should receWve the ‘The recommendation can be evaluated We recommend” want the recommended couree of | recommended course of action. 1s candidate for developing 2 policy ‘action, and only a small propatin for a performance measure would not Level 2 Weak? ‘The majorty of people in your situation Different choles willbe appropriate The recommendation & key 0 We suggest” ‘would want the recommended course for different patients. Each patent requte substantial debate and (of action, but many would net. needs help to ave at a management decision consistent with her or his values and preferences Involvement of stakeholders before policy cn be determined Gade Qualyy of evidence Meaning A High We are confident thatthe tre effect i los tothe estimate ofthe effet. 8 Moderate The tue effects hel to be cose tothe estimate ofthe effect, but there isa possiblity that tis substantially diferent © tow The tue efect may be substantially diferent from the estimate of the effec. D___Very tow ‘he estimate of eflect is very uncertain and often it wil be far fom the true elect se ida introrel 2021) 9, 51-87 snr kideyinternationa.org CKD nomenclature ‘CURRENT CHRONIC KIDNEY DISEASE (CKD) NOMENCLATURE USED BY KDIGO ‘CKD is defined as abnormalities of kidney structure or function, present for > 3 months, with implications for health. CKD is classified based on Cause, GFR category (G1-G5), and Albuminuria category (A1-A3), abbreviated as CGA. Persistent albuminuria categories Description and range Prognosis of CKD by GFR and se wera eone"“ronans” "tome cc ‘Green, low risk {if no other markers of kidney disease, no CKD), yellow, moderately increased risk; orange, high risk; ed, very high sk. GGFR, glomeruar filtration rat. ny ematond (021) 9, 51-587 2 conversion factors rw kidney interational.org CONVERSION FACTORS OF CONVENTIONAL UNITS TO SI UNITS Conventional unit Conversion factor ST Unit creatinine mad 884 molt Creatinine desrance eine 016s ns ALBUMINURIA CATEGORIES IN CKD [ACR (approximate equivalent catego AER (ng/24 ) (emgiramot (ng/) Terms a =30 3 =30 ‘Normal to milly increased n 30-300 + 20-300 Moderately increased B 200 >30 2300 Severely inreased [9c bum 5 min 2 Thepatiot shoud atid cafe exercise and smoking for atest 30min before measurement 4 Ersue pate fas empl hiner baddar 4 Nother tho patent oor the cher shoud talk uring the rst prod or during tho maasuroment 5 Removal clothing covering the location of uf placement 6 Mansurements made while te patient sting or ying on an examining table donottus texocitons 1 Usea BP measurement device that has been validated and ensure thatthe device iscalbrated pvocaly 2 Support epi sar esting ona dosh) 3 eatin the mide ofthe cf nthe patient's upper amt the evel ofthe ight atm he midpoint ofthe sternum) 4 Usethe conect ef si, such ta the blader ences 0% of the arm, an not atager-orsmatertnan noma cu sos wed 5 Eartne stetnscope phragm or bl maybe uted for uscuatory readings 1 At the ist vis record BP in both ams Use thearm that ves the higher reading orsubsequent readings 2 Separate repeated measurements 12min 3 Forausatatry determinations us a palpated estimate ofall pise obteraton pressure to estimate SP tate theca 20-30 mm ig above this levelferan asauatrydetamination ofthe BP lve 4 Forauscltatry readings deflate the calf pressure 2 mm Ha pe second and sen for Korea sounes 1 Recor SBP and DEP using the auscultatory technique record SP and DBP as ‘onset of the fst Korot sound and sappearance ol Korot sounds, tospectay using the noatest oven nue 2 Noto tho time of mostracant BP madison akon beero measurements Use anaverage of 22 eangsabtained on 2 2 occasions to estimate the india volt Provide paints wit the SBP/DBP readings vrbaly an inviting Figure 2| Checklist for standardized office blood pressure measurement. BP, blood pressure DEP, diastolic blood pressure; SEP, systolic blood pressure. Modification for pediatrics BP in infants should be taken while supine and the use of the bells recommended.’ Reprinted from the Journal ofthe American College of Cardiology, Velume 71, Whelton PK. Carey RM, Aronow WS, et a. 2017 ACC/AHA/AAPA/ABCIACPNVAGS/ [APRIVASH/ASPCINMAVPCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiclogy/American Heart Association Task Force cn Clinical Practice Guidelines, Pages e127-2248, © 2018 with permission from the American College of Cardiology Foundation and the American Heart Association, In.” 26 cy trina (1) 98, 81-587 nv kideyinterational.org chapter 1 Some oscillometric devices can be programmed to auto: matically provide a period of rest followed by multiple BP readings with a single activation, a method known as auto~ mated office BP (AOBP). AOBP can be performed either with the patient alone (je, unattended) or with a healthcare provider/technician present (ie. attended), whereas the other office BP. methods all require a healthcare provider to be present to perform the measurement. We suggest that AOBP is the preferred method of standardized office BP measure- ment (see Practice Point 1.2), but we have no preference for unattended versus attended measurement. Recommendation 1.1: We recommend standardized office BP measurement in preference to routine of- fice BP measurement for the management of high BP in adults (78). This recommendation places a relatively higher value on con- sistency with the BP measurement methods used to define BP targets in prior large clinical outcome trials. It abo places a higher value on avoidance of misclasification to prevent over- treatment or undertreatment of high BP. This recommendation places a lower value on the increased burden to patents, pro- viders, and staff This recommendation is strong because, inthe Work Group’ opinion, the importance of office BP measured ting a standardised versus a routine, non-standardized “approach outweighs any potential burden to its implementation. Key information Balance of benefits and harms. ‘’his recommendation relies heavily on the importance of standardized office BP mea surement protocols that are consistent with large randomized controlled trials (RCTS) with clinically important outcomes that have been used to define BP targets. Standardized office BP measurements allow for extrapolation of the RCT findings to clinical practice and avid overtreatment or undertreat- ‘ment of high BP that may occur if non-standandized mea- surements are used. ‘The negative aspects of standardized office BP measurement, including the increased burden on patient, provider, staff time, and clinic space, are outweighed by the benefits. Quality of evidence. There is moderate-quality evidence that routine office BP is generally, but not invariably, higher than standardized office BP, regardless of whether manual or oscillometric devices are used. However, there is strong evidence that the relationship between routine office BP and standardized office BP is highly variable among individuals. Thus, it is not possible to apply a correction factor to translate a given routine BP value to standardized office BP. Values and preferences. Appropriate BP. management re quires proper BP measurements. All large randomized BP ‘outcome trials used standardized office BP measurements. In the opinion of the Work Group, the importance of measuring BP in a manner that is consistent with the RCTs far outweighs the additional burdens and costs for providers, staff, and ny tematond (021) 9, 51-87 patients, Increased costs are due to personnel and clinic time utilization Routine office BP measurements are generally higher than standardized office BP measurements.” ‘Therefore, the use of routine ofce BP measurements for BP management could lead to overtreatment of BP and possibly result in a higher incidence of hypotension-related adverse events. Conversely, for some persons for whom routine office BP is lower than standardized office BP, use of routine office BP couldlead to undertreatmentof hhigh BP and result ina higher risk of future cardiovascular (CV) events. Routine and standardized BP measurements have poor agreement, including those in the CKD population.” It is, therefore not possible to comert a routine office BP into a standardized office BP using a correction factor in an individual. ‘Thus, in the opinion of the Work Group, most welkinformed patients would accept the additional time required for stan dardizad office BP measurement. Resource use and costs Siandardized office BP does not necessarily require additional equipment beyond the existing BP measurement devices. However, standardized office BP takes longer to perform than routine office BR given the need to follow proper preparatory procedures (Figure 2). There- fore, there may be an increased time burden on patients, providers, and staff. This approach also requires staf training and retraining to ensure that a standardized BP measurement approach is followed. Adequate access to @ quiet clinic space that allows for an adequate rest period prior to BP mea- surement may also be an isue in certain settings. However in the opinion of the Work Group, this recommendation is likely to be cost-effective as it may avert consequences of over- treatment and undertreatment, though an economic analysis has not been published. Considerations for implementation. ‘he use of standardized office BP over routine office BP holds true for all patients, regardless of age, sex, race, or CKD severity. Rationale ‘This chapter isan adlton since the KDIGO 2012. BP guide- line. ‘This recommendation places a relatively higher value on consistency with BP measurement methods used in prior outcome trials examining diffrent BP targets, and on mini- mizing overtreatment or undertreatment of BP that may result from routine, non-standardized offce BP measurements. This recommendation places a lower value on the increased time required to perform standardized BP measurements ‘This recommendation is consistent with other recent guidlines that also underscore the importance of standard ined office BP measurement (e.g,, American College of Car- diology [ACC|/American Heart Association (AHAI,”” and European Society of Cardiology (ESC]"). 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. sr chapter 1 rr kidney interationalorg Oscillometric BP devices may be preferred over manual BP devices, as the former minimizes potential sources of inac- curacies in BP measurements that can occur with human

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