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Guideline for the Management of Blood Pressure in CKD PowerPoint Presentation

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This medical PowerPoint presentation talks about Guideline for the Management of Blood Pressure in Chronic kidney disease (CKD).

Chronic kidney disease (CKD) is a common condition that can lead to high blood pressure (hypertension). Hypertension is a major risk factor for kidney damage, cardiovascular disease, and stroke. The guidelines for the management of blood pressure in CKD in the presentation include Blood pressure target, Lifestyle modifications, Medications, Monitoring, and Patient education.

Tags : Management of Blood Pressure in Chronic kidney disease, high blood pressure, hypertension, kidney damage, cardiovascular disease, stroke, cardiology, cardiology PowerPoint presentation

Published on : Mar 19, 2023 | Views : 964 | Downloads : 2

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KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in CKD KDIGO Guideline Co-Chairs: Alfred K. Cheung, MD Johannes F.E. Mann, MD Guideline: Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021;99(3S):S1–S87 Executive Summary: Cheung AK. Chang TI, Cushman WC, et al. Executive summary of the KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021; 99(3): 559–569
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Table of contents Introduction Guideline development process: Evidence review Guideline format Guideline statements and rationale from: Chapter 1. Blood pressure measurement Chapter 2. Lifestyle interventions for lowering blood pressure in patients with CKD not receiving dialysis Chapter 3. Blood pressure management in patients with CKD, with and without diabetes, not receiving dialysis Chapter 4. Blood pressure management in kidney transplant recipients (CKD G1T-G5T) Chapter 5. Blood pressure management in children with CKD Question and answer
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Guidelines KDIGO’s core mission. KDIGO is the only organization developing global guidelines in nephrology. Controversies Conferences International Conferences that examine significant topics in nephrology and related disciplines that are not fully resolved. Results in a published paper, usually in Kidney International. Often a Controversies Conference will prompt development of a guideline or a guideline update. Implementation Activities Dissemination and Implementation of KDIGO Guidelines Controversies Conference Reports and Observations Live Clinical Practice Conferences – usually with a nephrology society to bring global KDIGO’s work to local audiences, using case studies Implementation Summits bring local experts together to discuss local or regional barriers and opportunities Core Implementation Kits – educational materials including Speaker’s Guides, Reference Tools, and Case Studies to assist with implementation of all KDIGO publications KDIGO Programs
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KDIGO Controversies Conference on BP in CKD September 2017 (Edinburgh, Scotland) Topics: BP Measurement Management of Hypertension in CKD Patients with Diabetes vs. without Diabetes Management of Hypertension in CKD among Elderly and Individuals with Previous Stroke Management of Hypertension in CKD in Transplant and Pediatric Populations Report published in Kidney International (2019) Led to initiation of an update of the KDIGO BP clinical practice guideline
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Timeline of Guideline for BP Management in CKD
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KDIGO 2012 Guideline: The Beginning
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Scope of the Clinical Practice Guideline Include: Patients, adults and children, with CKD not receiving dialysis All CKD not receiving dialysis Kidney transplant recipients BP measurement techniques Interventions addressed with rigorous data (RCTs) Lifestyle Targets Pharmacotherapy Exclude: Dialysis patients Interventions covered elsewhere For example, lipids and BP in patients receiving dialysis Topics with insufficient data on the risks or benefits on BP in CKD Weight loss Reduction in alcohol consumption Emerging & pipeline therapies
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Guideline Goals Generate a useful resource for clinicians and patients Address relevant questions with actionable recommendations Take on controversial topics when sufficient evidence Communicate clearly Stay true to evidence Target audience: Primarily clinicians treating CKD patients, kidney transplant recipients, and children with high blood pressure Be mindful of implications for policy and payment Propose research questions
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Work Group Worldwide scope Prior GL WG Members Deep experience Evidence Review Team
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Work Group Missing from photo: Susan Furth, Sheldon Tobe
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What Is New Since the 2012 KIDGO Guideline More work and emphasis on techniques of BP Measurement SPRINT (Systolic Blood Pressure Intervention Trial) and SPRINT-MIND Joint analysis of SPRINT and ACCORD; more subgroup analyses of ACCORD Large meta-analysis in CKD or non-CKD population
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Evidence Review ERT - Cochrane Kidney Transplant Existing PICO questions and new PICO questions developed Clinical and important outcomes identified
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PICO Questions Focus on RCTs - mapped to existing Cochrane Systematic reviews New systematic reviews undertaken as required Some focused observational studies reviews General population - Existing systematic reviews
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Literature SearchOctober 2018; February 2019, and Final Update in April 2020
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Evidence Synthesis Standard Cochrane methods – Two independent reviewers Data abstraction Critical appraisal – using validated tools Data-analysis Random effects meta-analysis and generic inverse variance Relative risk for dichotomous outcomes Mean difference for continuous outcomes Heterogeneity assessed using the I2 statistic Risk of bias graph example Forest plot example – BP target – CV Mortality
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Grading Recommendations GRADE methodology The quality of the evidence – Level A, B, C, D Study limitations Inconsistency Indirectness Imprecision Publication bias Strength of the recommendation – Level 1, “We recommend” or Level 2, “We suggest” One face-to-face meeting – New Orleans Jan 2019 Balance of benefits and harms Quality of the evidence Patient values and preferences Resources and other considerations
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Guideline Format
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Guideline Format
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MAGICapp (Making GRADE the Irresistible Choice) Electronic guideline publishing software KDIGO is piloting this online platform to: directly link evidence to recommendations increase transparency of guideline process improve accessibility of guidelines through digital publishing create “living guidelines” that ease update process allow generation of patient decision aids www.magicevidence.org; www.magicapp.org
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MAGICapp – Evidence to Recommendation Summary of findings tables presented in MAGICapp Tables are linked directly to recommendations - transparency
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MAGICapp – Evidence to Recommendation Studies and references linked directly to tables Ease of updating – new studies added to existing evidence
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Blood Pressure in CKD Guideline Contents Chapter 1. Blood pressure measurement Chapter 2. Lifestyle interventions for lowering blood pressure in patients with CKD not receiving dialysis Sodium intake Physical activity Chapter 3. Blood pressure management in patients with CKD, with or without diabetes, not receiving dialysis Blood pressure targets Treatment with antihypertensive drugs, including RAS inhibitors (RASi) Role of dual therapy with RASi Chapter 4. Blood pressure management in kidney transplant recipients (CKD G1T-G5T) Chapter 5. Blood pressure management in children with CKD
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Blood Pressure Measurement Recommendation 1.1. We recommend standardized office BP measurement in preference to routine office BP measurement for the management of high BP in adults (1B).
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Blood Pressure Measurement
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Standardized BP Measurement Key is proper preparations Abstinence from caffeine, exercise and smoking for >30 min Feet on floor; arm and back supported Keep quiet (and not talked to) and relaxed for >5 min Use validated equipment Correct cuff size and position Advantages Employed in large RCTs (e.g., ACCORD and SPRINT) Minimizes misclassification and over-treatment or under-treatment of high BP Disadvantages Requires staff training and retraining Requires more time of patients, providers and staff
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Blood Pressure Measurement Practice Point 1.1: An oscillometric BP device may be preferable to a manual BP device for standardized office BP measurement; however, standardization emphasizes adequate preparations for BP measurement, not the type of equipment. Practice Point 1.2: Automated office BP (AOBP), either attended or unattended, may be the preferred method of standardized office BP measurement. Practice Point 1.3: Oscillometric devices can be used to measure BP among patients with atrial fibrillation. May increase likelihood of adherence to proper BP measurement protocols Removes potential sources of inaccuracies with manual measurement May reduce white-coat effect Frees staff to complete other duties Used in prior RCTs and prospective cohort studies But, probably not as important as proper preparations
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Blood Pressure Measurement Method and Device Used in Select RCTs and Prospective Observational Studies
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Blood Pressure Measurement Recommendation 1.2: We suggest that out-of-office BP measurements with ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) be used to complement standardized office BP readings for the management of high BP (2B).
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Lifestyle Interventions for Lowering BP in Patients with CKD not Receiving Dialysis Recommendation 2.1.1: We suggest targeting a sodium intake <2 g of sodium per day (or <90 mmol of sodium per day, or <5 g of sodium chloride per day) in patients with high BP and CKD (2C). Practice Point 2.1.1: Dietary sodium restriction is usually not appropriate for patients with sodium-wasting nephropathy. Practice Point 2.1.2: The Dietary Approaches to Stop Hypertension (DASH)-type diet or use of salt substitutes that are rich in potassium may not be appropriate for patients with advanced CKD or those with hyporeninemic hypoaldosteronism or other causes of impaired potassium excretion because of the potential for hyperkalemia.
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Lifestyle Interventions for Lowering BP in Patients with CKD not Receiving Dialysis Recommendation 2.2.1: We suggest that patients with high BP and CKD be advised to undertake moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with their cardiovascular and physical tolerance (2C). Practice Point 2.2.1: Consider the cardiorespiratory fitness status, physical limitations, cognitive function, and risk of falls when deciding on the implementation and intensity of physical activity interventions in individual patients. Practice Point 2.2.2: The form and intensity of physical activity should be considered and modified as necessary in individual patients. There may still be important health benefits even if physical activity falls below targets proposed for the general population.
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Blood Pressure Management in Patients with CKD, with or without Diabetes, not Receiving Dialysis CKD G4 and G5 Diabetes Individuals with SBP 120-129 mm Hg Patients with very low baseline diastolic BP, particularly in the presence of coronary artery disease Specific etiology of CKD Severely increased proteinuria Older age Younger age Very frail “White coat” hypertension Severe hypertension Recommendation 3.1.1: We suggest that adults with high BP and CKD be treated with a target systolic blood pressure (SBP) of <120 mm Hg, using standardized office BP measurement (2B). This recommendation is weak according to GRADE because there is less certainty that the benefits outweigh the harms in the following scenarios: Individualization is KEY
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Rationale for Target SBP <120 mm Hg in CKD For most patients with CKD, a cardiovascular event is a more likely outcome than ESKD.1 SPRINT confirmed cardiovascular and survival benefits in non-diabetic CKD.2 ACCORD showed marked reduction in stroke in diabetes, but only included 401 patients with eGFR <60 ml/min/1.73m2; nonetheless, benefits of SBP <120 mm Hg in the standard glycemia arm similar to those seen in SPRINT.3,4 Meta-analyses demonstrate reduction of CV risk proportional to BP lowering, though some show lower proportional risk reduction in the presence of CKD and of DM.5,6,7 1O’Hare J Am Soc Nephrol 2007;18: 2758. 2Cheung JASN 2017; 28: 2812. 3Papademetriou Am J Nephrol 2016; 43: 271. 4Tsuijimoto Hypertension 2018;72;323. 5BPLTC BMJ 2013;347:f5680; 6Ettehad Lancet 2016;387:435; 7Malhotra JAMA Int Med 2017;177:1498
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Low BP Target (<120 mm Hg) vs. Standard BP Target (<140 mm Hg) *Cheung AK, Rahman M, Reboussin DM, et al. Effects of Intensive BP Control in CKD. Journal of the American Society of Nephrology. 2017;28(9):2812-2823; Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. The New England Journal of Medicine. 2010;362(17):1575-1585 †Cheung AK, Rahman M, Reboussin DM, et al. Effects of Intensive BP Control in CKD. Journal of the American Society of Nephrology. 2017;28(9):2812-2823
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Meta-Analysis of Trials of Intensive vs. Less-Intensive BP Lowering in CKD on Mortality Outcome Malhotra R. JAMA Int Med 2017: 177: 1-8
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Intensive BP control causes initial drop in GFR, without increase in tubular injury markers, and with reduction in albuminuria – probably due to altered intrarenal hemodynamics. However, overall rate of decline in eGFR was higher with intensive BP control in SPRINT (in both CKD and non-CKD cohorts), ACCORD, and SPS. Difference in rate of decline after initial 6 months in SPRINT: 0.47 vs. 0.32 ml/min/1.73 m2/year in intensive vs. standard: if sustained over 20 y, this would cause only a 3 ml/min difference. Risk of CKD Progression with Intensive BP Lowering Therapy
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Blood Pressure Management in Patients with CKD, with or without Diabetes, not Receiving Dialysis Practice Point 3.1.1: It is potentially hazardous to apply the recommended SBP target of <120 mm Hg to BP measurements obtained in a non-standardized manner. Practice Point 3.1.2: Clinicians can reasonably offer less intensive BP-lowering therapy in patients with very limited life expectancy or symptomatic postural hypotension.
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Challenges for Implementation of SBP Target SBP <120 mm Hg conflicts with some, but not all national and international guidelines Resource implications Standardized office BP measurement (supplemented by ABPM or HBPM) Costs of intensive BP control Direct costs of drug therapy Indirect costs – e.g. electrolyte monitoring
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Blood Pressure Management in Patients with CKD, with or without Diabetes, not Receiving Dialysis Recommendation 3.2.1: We recommend starting renin-angiotensin-system inhibitors (RASi) (angiotensin-converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB]) for people with high BP, CKD, and severely increased albuminuria (G1-G4, A3) without diabetes (1B). Cardiovascular events in patients with CKD G3-G4, A3 without diabetes
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Blood Pressure Management in Patients with CKD, with or without Diabetes, not Receiving Dialysis Recommendation 3.2.2: We suggest starting RASi (ACEi or ARB) for people with high BP, CKD, and moderately increased albuminuria (G1-G4, A2) without diabetes (2C). Recommendation 3.2.3: We recommend starting RASi (ACEi or ARB) for people with high BP, CKD, and moderately-to-severely increased albuminuria (G1 to G4, A2 and A3) with diabetes (1B).
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Blood Pressure Management in Patients with CKD, with or without Diabetes, not Receiving Dialysis SPRINT protocol
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Blood Pressure Management in Patients with CKD, with or without Diabetes, not Receiving Dialysis Practice Point 3.2.1: It may be reasonable to treat people with high BP, CKD, and no albuminuria, with or without diabetes, with RASi (ACEi or ARB). Practice Point 3.2.2: RASi (ACEi or ARB) should be administered using the highest approved dose that is tolerated to achieve the benefits described because the proven benefits were achieved in trials using these doses. Practice Point 3.2.3: Changes in BP, serum creatinine, and serum potassium should be checked within 2-4 weeks of initiation or increase in the dose of a RASi, depending on the current GFR and serum potassium. Practice Point 3.2.4: Hyperkalemia associated with use of RASi can often be managed by measures to reduce the serum potassium levels rather than decreasing the dose or stopping RASi.
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Blood Pressure Management in Patients with CKD, with or without Diabetes, not Receiving Dialysis Practice Point 3.2.5: Continue ACEi or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation of treatment or an increase in dose. Practice Point 3.2.6: Consider reducing the dose or discontinuing ACEi or ARB in the setting of either symptomatic hypotension or uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms while treating kidney failure (estimated glomerular filtration rate [eGFR] <15 ml/min per 1.73 m2). Practice Point 3.2.7: Mineralocorticoid receptor antagonists are effective for management of refractory hypertension but may cause hyperkalemia or a reversible decline in kidney function, particularly among patients with low eGFR.
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Blood Pressure Management in Patients with CKD, with or without Diabetes, not Receiving Dialysis Recommendation 3.3.1: We recommend avoiding any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy in patients with CKD, with or without diabetes (1B).
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Blood Pressure Management in Kidney Transplant Recipients (CKD G1T-G5T) Practice Point 4.1. Treat adult kidney transplant recipients with high BP to a target BP of <130 mm Hg systolic and <80 mm Hg diastolic using standardized office BP measurement (see Recommendation 1.1.). Recommendation 4.1. We recommend that a dihydropyridine calcium channel blocker (CCB) or an ARB be used as the first-line antihypertensive agent in adult kidney transplant recipients (1C).
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Rationale for Target Practice Point in Kidney Transplant No informative RCT evidence for optimal BP target in Kidney Transplant Recipients (KTRs). KTRs value graft survival highly, and many would value death with a functioning graft more highly than return to dialysis.1 Intensive BP control associated with a higher (albeit slightly) rate of loss of GFR over time in SPRINT and a higher risk of “AKI” (single, denervated kidneys may be at higher risk). 1Tong A. Transplantation 2017; 101: 1887-1896
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CCB vs. Placebo/No Treatment for the Outcome of Graft Loss Non-dihydropyridine Dihydropyridine
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Blood Pressure Management in Children with CKD Recommendation 5.1: We suggest that in children with CKD, 24-hour mean arterial pressure (MAP) by ABPM should be lowered to ≤50th percentile for age, sex, and height (2C). Practice Point 5.1: We suggest monitoring BP once a year with ABPM, and monitoring every 3–6 months with standardized auscultatory office BP in children with CKD. Practice Point 5.2: In children with high BP and CKD, when ABPM is not available, manual auscultatory office BP obtained in a protocol-driven standardized setting targeting achieved SBP <90th percentile for age, sex, and height of normal children is a reasonable approach. Practice Point 5.3: Use ACEi or ARB as first-line therapy for high BP in children with CKD. These drugs lower proteinuria and are usually well tolerated, but they carry the risk of hyperkalemia and have adverse fetal risks for pregnant women.
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Rests heavily on ESCAPE trial: Probable benefit in slowing CKD progression, and reducing left ventricular hypertrophy, with no increased risk of adverse events. Children with proteinuria may benefit more; risks may be higher in those with salt-wasting disease. Rationale for BP Target Recommendation in Children Escape Trial Study Group. NEJM 2009: 361: 1639-1650
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Top 10 Key Takeaways for Clinicians
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Main Points of Controversy
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Main Points of Controversy
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Overall Summary Update to 2012 KDIGO guideline on BP Management in CKD Provide recommendations and practice points on: BP measurement Lifestyle interventions for lowering BP in patients with CKD not receiving dialysis BP management in patients with CKD, with or without diabetes, not receiving dialysis; in kidney transplant recipients (CKD G1T-G5T); and in children in CKD Standardized blood pressure measurement is consistent with large clinical trials with clinically important outcomes that used this measurement technique to define BP targets. CKD patients with high BP should limit their salt intake and undertake moderate intensity physical activity. CKD patients with high BP should be treated to a SBP target of <120 mm Hg using standardized office BP measurement. Individualization is KEY! RASi (ACEi or ARB) should be used in patients with CKD and increased albuminuria, with or without diabetes. the recommendation and evidence in those with severely increased albuminuria and in diabetic patients with moderately increased albuminuria are particularly strong. Kidney transplant recipients should be treated to a target of <130/<80 using standardized office BP measurement. Children with CKD should be treated to lower 24h MAP by ABPM to ≤50th percentile for age, sex, and height.
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Central Illustration
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Potential Implications Kidney International 2021 99686-695DOI: (10.1016/j.kint.2020.12.019)
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Question and Answer