*For medical professionals only
“img class=”responsive ” sizes=”(min-width: 320px) 320px, 100vw” src=”https://mmbiz.qpic.cn/mmbiz_png/x5F5KAyDKw19I4VvcibrfNia7lD1fial5KribXqZxjxMxtoc3ichKKz6ib3w5kJias8QNRBYGn80MM0AxEgOvRLibqE2uw/640″ width=”6400″ >KDIGO, a global non-profit organization, formed a working group to develop and implement the KDIGO 2021 Clinical Practice Guidelines for Blood Pressure Management in Patients with Chronic Kidney Disease. KDIGO guidelines recommend that most patients with hypertension (BP) and chronic kidney disease (CKD) should aim for systolic blood pressure <120 mmHg.
This guideline draws heavily from the results of the SPRINT trial [which recruited a large number of people aged ≥50 years with an eGFR of 20-59mL/min/1.73m2 , proteinuria <1g/d, non-diabetic CKD patients with systolic blood pressure 130-180mmHg];The strength of this recommendation is considered weak by the Evidence Review Panel due to serious risk of bias (Level 2) and rated the quality of the evidence as moderate (B).
In 2021, the KDIGO recommendation was expanded to include nearly all CKD patients who did not meet the SPRINT inclusion criteria (dialysis patients, kidney transplant recipients, and children were excluded), but the recommendation Whether the benefits of treatment outweigh the harms is unclear.
Recently, JACC magazine published a review article to discuss this issue, let’s take a look.
The 2021 KDIGO guidelines define hypertension as systolic blood pressure above the therapeutic target.
Therefore, the following people need antihypertensive treatment:
Individuals with a systolic blood pressure of 120-129mmHg
li>
Individuals with severe hypertension:
< p> e.g. systolic blood pressure >180mmHg without or with 1 antihypertensive drug,
or when using >4 antihypertensive drugs, systolic blood pressure ≥150mmHg.
The recommendations for treatment thresholds are more aggressive than those in the 2017 ACC/AHA guidelines and the 2012 KDIGO guidelines.
KDIGO 2021 guidelines adopt 2017 ACC/AHA guidelines for in-office blood pressure measurement .
Standardized BP measurements reduce poor or inaccurate measurements associated with random BP readings,
But it does not eliminate the office “white coat” effect, even when taking measurements with automated oscillometric BP equipment in the presence of an observer.
The recommended method of office blood pressure measurement may result in high blood pressure readings and lead to more aggressive treatment than SPRINT, but the consequences are unknown.
KDIGO 2021 guidelines also recommend the use of ambulatory or home blood pressure monitoring for out-of-office blood pressure measurements to supplement standardized office blood pressure readings.
The SPRINT Ambulatory Blood Pressure Adjunctive Study, designed to evaluate the impact of intensive outpatient-based hypertension treatment on ambulatory blood pressure, found that in patients using only automatic Daytime ambulatory systolic blood pressure in the <120 mmHg group was 6.8 mmHg higher than outpatient systolic blood pressure as measured by an oscillometric blood pressure device in most cases without the presence of the investigator.
Although the clinical significance of this observation is unclear, it raises questions about the role of out-of-office blood pressure measurement recommended by many authorities in the diagnosis and treatment of hypertension.
For example, CKD patients with office systolic blood pressure control <120mmHg and daytime systolic blood pressure elevation (≥120mmHg) (33.6% of SPRINT substudy participants) should receive Additional antihypertensive drugs for masked hypertension?
Observational studies in non-CKD and CKD patients suggest that this BP phenotype is associated with an increased risk of cardiovascular disease (CVD) and all-cause mortality.
Currently, there are no randomized trials of ambulatory or home blood pressure goals addressing this question.
A recent study published in JACC , we assessed other patients with grade 3 and 4 chronic kidney disease requiring antihypertensive medication using 2 databases in Korea ([KNHANES] and [NHIS]), using the 2021 KDIGO guidelines to assess the proportion of patients requiring treatment potential impact. Associations with cardiovascular outcomes were assessed using NHIS data.
It was found that according to the 2021 KDIGO Guidelines:
Adults with CKD who were eligible for blood pressure had the highest weighted proportion (66.1%).
Compared with those with blood pressure within two target ranges (2021 KDIGO target and 2017 ACC/AHA target),
Multivariate Adjusted HR for CVD Events:
Individuals with blood pressure above both targets, HR 1.41 (95%CI: 1.36-1.45),
individuals only above the 2021 KDIGO target, HR 1.18 (95%CI: 1.13-1.22)
Individuals only above the 2017 ACC/AHA target, HR 1.09 (95%CI: 0.95-1.25).
CVD risk:
Blood pressure within the 2021 KDIGO target range (ie, SBP <120mmHg) with reduced risk of CVD events.
The target is higher than the 2021 KDIGO target (ie, SBP ≥ 120 mmHg), and the risk of CVD is higher.
Compared with participants whose blood pressure was within both target ranges (2021 KDIGO target and 2017 ACC /AHA target),
participants with blood pressure above both guideline targets, or blood pressure above the 2021 KDIGO target were at higher risk for CVD.
There was no significant increase in CVD risk among those whose blood pressure was only above the 2012 KDIGO target, or the blood pressure was only above the 2017 ACC/AHA target.
The data results for the comparison of KDIGO in 2021 and KDIGO in 2012 are similar.
This Korean study:
Provides new information on the group of patients with elevated diastolic blood pressure and normal systolic blood pressure who are not recommended for treatment according to 2021 KDIGO.
This group is small, accounting for 3%-5% of the total CKD population, and the risk of CVD events is not significantly higher than that of the reference group (Controlled within two target ranges).
Consistent with the SPRINT findings, these findings are not important for the management of diastolic blood pressure in elderly patients with CKD. However, as shown in a BP study of 1.3 million US adults, diastolic hypertension remains an independent risk factor for CVD and its importance cannot be ignored.
Currently, evidence is lacking to examine the relationship between diastolic hypertension and outcomes independent of systolic blood pressure levels in patients with CKD.
The results of this South Korean study and the results of a US study Consistent (the study estimated the proportion of U.S. adults with CKD who met the KDIGO guidelines for blood pressure lowering at 69.5% using data from the 2015-2018 National Health and Nutrition Examination Survey), meaning that approximately 24.5 million U.S. adults with CKD require additional antihypertensive control Blood pressure, which is a major challenge facing the medical community.
new The 2021 KDIGO BP guidelines expand the indications for antihypertensive therapy, affecting more than 10% of patients with CKD (a significantly higher CVD risk than those with well-controlled blood pressure).
Intensive blood pressure control, further lowering the systolic blood pressure <120 mmHg target, may bring additional benefits to patients with CKD the benefits of.
Source:
Implications of Implementing the 2021 KDIGO Blood Pressure Guideline. J Am Coll Cardiol. 2022;79(17):1687-1689. doi: 10.1016/j.jacc.2022.02.038.
< p>Author:Liu Xinmeng Capital Medical University< /span>Affiliated Beijing Anzhen Hospital
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