Speaker discusses Kidney Disease: Improving Global Outcomes guideline updates
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BOSTON — In a review of the Kidney Disease: Improving Global Outcomes recommendations, a speaker discussed the Kidney Disease Outcomes Quality Initiative commentary on the updated guidelines here.
Specifically, the speaker said the updates focused on blood pressure measurement techniques and blood pressure targets.
“An important feature of these guidelines was a glossary of terms for blood pressure measurement,” Paul E. Drawz, MD, MHS, MS, associate professor at the University of Minnesota, said during a presentation at the National Kidney Foundation Spring Clinical Meetings. He added, “These guidelines included practice points that were expert opinion that can guide clinical care and inform decisions made between providers and patients.”
Recommendation on blood pressure measurement
The updated Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend providers use the standardized office blood pressure method for measuring blood pressure instead of routine measurement.
Drawz compared studies between the 1970s and 2015 showing routine vs. standard blood pressure techniques to reveal most are often biased. As routine blood pressure is usually taken at the time of referral, the blood pressure is often elevated. Therefore, standard blood pressure techniques seem to be best, he said.
“It’s worth noting that KDIGO and [Kidney Disease Outcomes Quality Initiative] KDOQI are not alone,” Drawz said. “Every single blood pressure guideline in existence at this point recommends standard blood pressure measurement.”
KDIGO guidelines also suggested that out-of-office BP measurements with ambulatory blood pressure monitoring or home blood pressure monitoring be used to complement standardized office blood pressure readings for the management of high blood pressure.
According to Drawz, KDOQI agrees with the suggestion but stresses the need for more research evaluating the impact of ambulatory blood pressure monitoring or home blood pressure monitoring based treatment on outcomes and cost.
Blood pressure management with CKD, with or without diabetes or not on dialysis
“I’m going to turn to what is a controversial topic, and that is, ‘What should the target blood pressure be?” Drawz said. He added, “KDIGO suggests that adults with high blood pressure and [chronic kidney disease] CKD be treated with a target systolic blood pressure of less than 120 mmHg, when tolerated, using standardized office blood pressure measurement.”
Drawz referenced studies to show target blood pressure over time, specifically the 2015 SPRINT study. All patients in the randomized trial of intensive vs. standard blood pressure control had a systolic blood pressure between 130 150 mmHg and 150 mmHg and were at risk for adverse events. Patients were randomized to an intensive group (clinic systolic blood pressure target < 120 mmHg) or a standard group (clinic systolic blood pressure target < 140 mmHg). Results revealed the intensive treatment correlated with a 25% reduction in the primary outcome of a composite of myocardial infarction, other acute coronary syndrome, stroke, heart failure and death from cardiovascular causes.
According to Drawz, KDOQI agrees with the suggested target of less than 120 mmHg for patients without diabetes.
“While KDIGO suggested less than 120 [mmHg] for all patients without CKD, the KDOQI commentary breaks it up into suggestions for non-diabetics and a separate suggestion for those with diabetes,” Drawz said. He added, “In conclusion, proper blood pressure measurement technique is critical. For non-diabetic patients with CKD, we agree that a systolic blood pressure target of less than 120 [mmHg] is reasonable. In diabetic patients with CKD, systolic blood pressure target of less than 130 [mmHg] is reasonable. The appropriate target in patients with advanced CKD and end-stage kidney disease is unknown.”
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Drawz PE. KDOQI commentary on the KDOQI blood pressure guidelines. Presented at: National Kidney Foundation Spring Clinical Meetings; April 5-10, 2022; Boston.
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