KDIGO Practice Guideline: BP Management in Chronic Kidney Disease

An update to the KDIGO clinical practice guidelines was published for the management of blood pressure in CKD.

The Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines from 2012 have been updated and now include 11 recommendations and 20 practice points emphasizing a standard blood pressure (BP) target for systolic BP <120 mm Hg among patients with chronic kidney disease (CKD) and high BP who do not receive dialysis. A synopsis of the KDIGP 2021 was published in the Annals of Internal Medicine.

For patients with CKD who have high BP and do not require dialysis, the guidelines recommend patients be monitored by a standard BP assessment during clinical visits, preferably with an oscillometric device. Appropriate office BP procedures should include the proper preparation, such as ensuring the patient is relaxed, has an empty bladder, has not consumed caffeine or tobacco for 30 minutes, does not have clothing interfering with the BP cuff, and that no conversation occurs during assessment.

At an initial patient visit, BP should be assessed in both arms. At future check-ups, BP should be measured in the arm which gives a higher BP. The patient’s average BP should be formulated from ³2 readings recorded on ³2 visits. At each clinic visit, the patient should be informed of their BP both verbally and in writing.

The KDIGO recommends for a systolic BP target of <120 mm Hg, especially among individuals aged >50 years or with high risk for cardiovascular disease.

In order to achieve this BP target, patients should be advised to limit sodium intake to <2 g per day and to engage in moderate-intensity physical activity for ³150 minutes per week.

For patients in need of pharmacological interventions, the KDIGO recommends the highest approved dose of renin-angiotensin system inhibitors (RASIs). Patients using RASIs should be monitored for changes in BP and serum creatinine and potassium 2-4 weeks after treatment initiation for dose titration. Combinatorial therapy with direct renin inhibitors is not recommended.

Among the subset of patients who have received a kidney transplant, the BP targets should be <130 mm Hg systolic and <80 mm Hg diastolic pressures. The most appropriate pharmacological options include dihydropyridine calcium channel blockers or angiotensin II receptor blockers (ARBs).

For the pediatric population with CKD and high BP, the target should be £50th percentile based on their age, gender, and height. Children should be assessed for BP every 3-6 months with ambulatory BP monitoring. First-line therapy options are angiotensin converting enzyme inhibitors or ARBs.

The summary authors concluded that patients with CKD and elevated BP are at higher risk for cardiovascular disease and death than kidney failure. As such, managing high BP is of upmost importance. Recent evidence has demonstrated the benefits of intensive BP lowering among this patient population, leading the committee to recommend a systolic BP target of <120 mm Hg.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Tomson CRV, Cheung AK, Mann JFE, et al. Management of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice Guideline. Ann Intern Med. Published online June 22, 2021. doi:10.7326/M21-0834