Chapter 3: Blood pressure management in CKD ND patients without diabetes mellitus

INTRODUCTION This chapter addresses the management of BP in adult CKD patients (specifically non-dialysis-dependent CKD [CKD ND]) without diabetes mellitus. There is overlap with BP management in the elderly (defined as persons 465 years of age or as persons with CKD and aging-related co-morbid conditions). In the elderly in particular and to a lesser extent in younger CKD patients, these co-morbid conditions may require modifications in the approach to BP management. In this chapter we consider two primary adverse outcomes related to high BP: progression of kidney disease and development of CVD. The data are sufficient to provide recommendations on BP targets and the use of ACE-Is or ARBs, although there is evidence of heterogeneity in both areas according to the urine albumin level. We therefore divided the target populations on the basis of urine albumin level. We did not find sufficient data to suggest any differences according to CKD stage, so our recommendations are not stage-specific. It is not possible to recommend specific regimens or BP targets for all the various causes of CKD. Although there are strong observational data, there is no evidence from RCTs to indicate that the treatment approach should differ substantially for the patient with glomerular disease and high urine albumin levels compared to the patient with severe renovascular disease. Although we would have preferred to give a target range (lowest to highest) for BP rather than a single target for highest acceptable BP, there are insufficient data based on RCTs to recommend a target for lowest BP level. The recommendations and suggestions in this chapter therefore emphasize an approach based on highest acceptable BP and severity of albuminuria, but the interventions should be implemented cautiously and with subsequent surveillance for adverse effects. We also recognize that BP agents other than those recommended or suggested below, such as diuretics, may be necessary for BP control, especially as CKD progresses and volume retention becomes more of an issue. However, few RCTs addressing hard cardiovascular or kidney outcomes have randomized patients to a diuretic versus another agent on top of an ACE-I or ARB. Therefore, in contrast to the 2004 KDOQI guideline, we do not provide a guideline statement regarding diuretic use as a preferred second-line agent. The use of diuretics and other BP agents are discussed in more detail below and in Chapter 2. 3.1: We recommend that non-diabetic adults with CKD ND and urine albumin excretion o30 mg per 24 hours (or equivalent*) whose office BP is consistently 4140 mm Hg systolic or 490 mm Hg diastolic be treated with BP-lowering drugs to maintain a BP that is consistently r140 mm Hg systolic and r90 mm Hg diastolic. (1B)