The following are key points to remember from the Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline for the management of blood pressure (BP) in patients with chronic kidney disease (CKD) not receiving dialysis:

1. The importance of standardized office BP measurement is strongly emphasized. An oscillometric or manual BP device may be used, and BP may be measured with or without a medical professional present (attended or unattended). The patient should sit with his/her feet on the floor for ≥5 minutes prior to measurement.
2. Ambulatory or home BP monitoring may be used to complement standardized office BP readings, as observational studies have shown that out-of-office BP readings correlate more strongly with kidney and cardiovascular outcomes than office readings. However, no large randomized controlled trials have targeted out-of-office BPs in adults.
3. The authors suggest that adults with high BP and CKD be treated to a target systolic BP (SBP) of <120 mm Hg, when tolerated. This is a weak recommendation based on moderate-quality evidence, largely from the SPRINT trial (N Engl J Med 2015;373:2103-16).
4. The SBP target of <120 mm Hg is recommended with greater certainty among patients >50 and <80 years old and those at high risk for cardiovascular disease, and with less certainty among patients with diabetes, stage 4 or 5 CKD, severe albuminuria (albuminuria category A3, albumin/creatinine ratio >300 mg/g), prior stroke, very low diastolic BP (DBP), and severe hypertension.
5. The SBP treatment target of <120 mm Hg should not be applied to BP measurements obtained in a nonstandardized manner, given the risk of excessive BP lowering.
6. With regard to lifestyle interventions, patients with high BP and CKD should limit dietary sodium intake to <2 g daily, though DASH-type diets may not be appropriate for patients with advanced CKD or hypoaldosteronism because of hyperkalemia risk. Patients should engage in moderate-intensity physical activity for ≥150 minutes per week, if tolerated.
7. In patients with albuminuria, with or without diabetes, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) should be used to treat elevated BP. The evidence supporting this recommendation is strongest for patients with severe albuminuria (albuminuria category A3). Notably, a recent KDIGO statement on early identification of CKD recommended screening all patients with cardiovascular disease, hypertension, and diabetes for CKD with dual assessment of serum creatinine and urine albumin/creatinine ratio (Shlipak MG, et al., Kidney Int 2021;99:34-47).
8. Future updates of the guideline will address use of finerenone, a nonsteroidal mineralocorticoid receptor antagonist, in patients with high BP and CKD. The FIDELIO-DKD trial, which enrolled patients with diabetic kidney disease and albuminuria, demonstrated a reduction in cardiovascular and kidney endpoints with the addition of finerenone to a background of ACEI/ARB therapy, with an increased risk of hyperkalemia (Bakris GL, et al., N Engl J Med 2020;383:2219-29).
9. In adult kidney transplant recipients, target BP should be <130/80 mm Hg, extrapolated from trials demonstrating a reduction in mortality and cardiovascular events with this BP target in the general population. First-line antihypertensives in this population should be dihydropyridine calcium channel blockers and ARBs.
10. Recommended subjects of future research are many and include use of home and ambulatory BPs as treatment targets, diuretics for BP lowering in CKD, and influences of patient values and preferences on BP-lowering therapy.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Prevention, Diet, Exercise, Hypertension

Keywords: Albuminuria, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Calcium Channel Blockers, Creatinine, Diabetes Mellitus, Diet, Sodium-Restricted, Dihydropyridines, Diuretics, Exercise, Geriatrics, Hyperkalemia, Hypertension, Hypoaldosteronism, Kidney Transplantation, Life Style, Metabolic Syndrome, Mineralocorticoid Receptor Antagonists, Primary Prevention, Renal Dialysis, Renal Insufficiency, Chronic, Sodium, Dietary, Stroke

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