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Optimal targets for blood pressure control in chronic kidney disease: the debate continues
John Knight1, Muh Geot Wong, Vlado Perkovic
1aThe George Institute for Global Health bSydney Medical School, University of Sydney cRoyal North Shore Hospital, Sydney, New South Wales, Australia.
Insights
Revised hypertension guidelines may not apply to advanced chronic kidney disease (CKD). New evidence is limited, and a risk-based approach might be more beneficial than strict targets for CKD patients.
Area of Science:
- Nephrology
- Cardiology
- Clinical Practice Guidelines
Background:
- Advanced chronic kidney disease (CKD) often excludes patients from major hypertension trials.
- Clinical decisions for these patients rely on limited data and extrapolation.
- Recent hypertension management guidelines have been updated.
Purpose of the Study:
- To evaluate the applicability of revised hypertension treatment guidelines to patients with advanced CKD.
- To review current evidence and recommendations for managing hypertension in CKD.
Main Methods:
- Review of recent meta-analyses, guidelines, and clinical trial data.
- Analysis of three major revised guidelines: KDIGO, JNC8, and KHA-CARI.
- Assessment of evidence strength and generalizability for CKD populations.
Main Results:
- New trial data for advanced CKD is scarce; most new publications are guidelines and meta-analyses.
- Most guidelines recommend a blood pressure target <140/90.
- Guidelines suggest a stricter target of <130/80 for proteinuric renal disease, favoring ACE inhibitors or ARBs.
Conclusions:
- Evidence for managing hypertension in advanced CKD is limited and less generalizable.
- A risk-based approach to intervention may be as valuable as target-based strategies.
- Future clinical trials in advanced CKD are needed, potentially exploring agents like spironolactone.
Purpose Of Review:
Because advanced chronic kidney disease (CKD) is often an exclusion criterion for large randomized trials of the management of hypertension, clinical decision making for these patients has relied on a few small, specific studies and much extrapolation. Several blood pressure treatment guidelines have recently been reissued. This review explores the applicability of the revised recommendations to CKD.
Recent Findings:
Many new publications are meta-analyses, guidelines and debates about guidelines. New data from trials are scant. Three revised guidelines (KDIGO, JNC8, KHA-CARI) recommend a target of less than 140/90. Most antihypertensive drugs are equally effective - but this rule may not apply to advanced CKD. Proteinuric renal disease is seen as an exception; all three guidelines set a target of 130/80 and the use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (but not both) is preferred.
Summary:
There is no shortage of new commentary and advice, but evidence strength and generalizability diminish as the kidneys fail and the impact of calcified vessels and salt and water overload increases. A risk-based approach to intervention may be no less valuable than targets. Clinical trials of individuals with advanced CKD will be needed to identify effective treatments and may see a resurgence of the role of spironolactone.
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