New KDIGO blood pressure targets affect more than 10% of patients with CKD
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The expanded indication for BP-lowering treatment by the 2021 Kidney Disease: Improving Global Outcomes guideline affects more than 10% of patients with chronic kidney disease, who are at higher CVD risk than those with well-controlled BP.
In an analysis of Korea National Health and Nutrition Examination Survey data, researchers also found that 3% to 5% of patients with chronic kidney disease (CKD) are no longer provided any indication for antihypertensive therapy by the new guideline, “whose CVD risk seems equivocal at this stage.”
“Intensive BP control to a further lowered target of systolic BP of less than 120 mm Hg may confer additional benefits to those with CKD,” Hyeon Chang Kim, MD, PhD, of the department of preventive medicine at Yonsei University College of Medicine in South Korea, and colleagues wrote in the Journal of the American College of Cardiology.
Reframing BP targets
As Healio previously reported, Kidney Disease: Improving Global Outcomes (KDIGO) revised its guideline on managing BP in patients with CKD in early 2021. The new optimal target, according to KDIGO, is a systolic BP less than 120 mm Hg, which is lower than what was recommended in 2012 (< 130 mm Hg). This change is due to the “cardioprotective, survival, and potential cognitive benefits as shown in the SPRINT trial,” the organization wrote.
“Likewise, patients requiring BP reduction per the 2021 KDIGO BP guideline can differ from those per the 2017 American College of Cardiology/American Heart Association BP guideline, which recommends a universal target BP of < 130/80 mm Hg for people with or without CKD,” the researchers wrote.
Kim and colleagues examined the proportions of concordance and discordance between the 2021 KDIGO BP target, the 2012 KDIGO BP targets and the 2017 ACC/AHA BP targets among 1,939 adults with CKD but not on dialysis, using Korea NHANES data (2011-2014; median age, 59 years; 50.6% men). Researchers than evaluated the associations of each concordance/discordance group with CV outcomes, using Korean National Health Insurance Service (NHIS) data (n = 412,167; median age, 65 years; 43.5% men). Adults were stratified into four groups: those above both KDIGO BP targets; those above 2021 KDIGO BP target only; those above 2012 KDIGO or 2017 ACC/AHA targets only; and those controlled within both targets.
The proportions of CKD patients requiring BP-lowering treatment were 53.7% per the 2012 KDIGO guideline, 60.4% per the 2017 ACC/AHA guideline and 66.1% per the 2021 KDIGO guideline, according to researchers.
Within the cohort, 50.2% of adults had a BP above both the 2021 and 2012 KDIGO targets, 15.9% were above the 2021 KDIGO target only, 3.5% were above the 2012 KDIGO target only and 30.4% were controlled within both targets.
Compared with adults with BP controlled within both targets, adjusted HRs for CVD events were 1.52 (95% CI, 1.47-1.58) among participants with BP above both targets, 1.28 (95% CI, 1.24-1.32) among those with BP above 2021 KDIGO only, and 1.07 (95% CI, 0.61-1.89) among those with BP above 2012 KDIGO only, using NHIS data (median follow-up, 10 years).
Results were similar when researchers compared the 2021 KDIGO and 2017 ACC/AHA BP targets.
“Participants who had BP above the 2021 KDIGO target (ie, systolic BP 120 mm Hg) exhibited a significantly higher CVD risk regardless of whether the other (2012 KDIGO or 2017 ACC/AHA) target was met or not,” the researchers wrote. “In contrast, those who had BP within the 2021 KDIGO target (ie, systolic BP < 120 mm Hg) showed a reduced risk for CVD events regardless of whether the other target was met or not.”
Growing need for BP treatment
In a related editorial, Alexander G. Logan, MD, professor of medicine at the University of Toronto and senior scientist in the Lunenfeld-Tanenbaum Research Institute of the Mount Sinai Hospital in Toronto, wrote that the study provides valuable information on patients with elevated diastolic BP but normal systolic BP, who would not receive treatment based on the 2021 KDIGO recommendations.
“The group was small, accounting for 3% to 5% of the total CKD population, and the risk of a CVD event was not significantly higher than in the reference group (controlled within both targets),” Logan wrote. “In concert with SPRINT findings, these results assign little importance to diastolic BP in managing hypertension of older CKD patients.”
Additionally, the findings align with a U.S. study using data from the 2015-2018 NHANES, which estimated that 69.5% of U.S. adults with CKD were eligible for BP lowering according to the KDIGO guidelines, translating to 24.5 million people, Logan wrote. He called the number of patients needing intensive BP treatment a “major challenge facing the medical community.”
“Undoubtedly, a multipronged approach will be required to address the swelling number of people needing more intense treatment, especially against a background of falling rates of BP control in the general community,” Logan wrote.
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