Optimal targets for blood pressure control in chronic kidney disease: the debate continues.

Abstract

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. 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. 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.