Limited Adoption of KDIGO BP Target in CKD

Key Takeaways

• In Mass General Brigham adults with stage 3 or 4 CKD, only about one in five patients were within the 2021 KDIGO systolic blood pressure target by 2024.
• Attainment of the KDIGO systolic blood pressure goal increased only marginally from 2020 to 2024.
• Antihypertensive medication burden changed very little over the same period.
• Systolic blood pressure above target was associated with higher cardiovascular and kidney failure risk, lower hypotension risk, and no reported differences in the other named safety outcomes.

Applying a systolic blood pressure goal below 120 mm Hg in older adults with stage 3 to 4 chronic kidney disease involves a practical tension between guideline ambition and everyday measurement conditions. Multimorbidity, polypharmacy, and concern about treatment-related harms can complicate efforts to translate a lower office target into routine care. That tension is sharpened by the difference between the 2021 Kidney Disease: Improving Global Outcomes threshold of less than 120 mm Hg and the 2017 American College of Cardiology/American Heart Association threshold of less than 130 mm Hg, with the lower Kidney Disease: Improving Global Outcomes target tied to standardized blood pressure measurement as in SPRINT. Adults with stage 3 to 4 chronic kidney disease in the Mass General Brigham network formed the basis for the investigators' assessment of how that target was used in routine care.

Using Mass General Brigham data, Lee HH and colleagues in the Journal of the American Society of Nephrology reported complementary analyses. A serial cross-sectional analysis assessed adults with stage 3 or 4 chronic kidney disease (CKD) each year from 2020 through 2024. A separate longitudinal analysis evaluated 18,996 patients with incident stage 3 or 4 CKD between 2014 and 2019. Outcomes in that cohort included kidney failure, cardiovascular disease (CVD), and the safety outcomes of hypotension, syncope, bradycardia, electrolyte abnormalities, and injurious falls.

In the KDIGO target attainment analysis in CKD, the proportion meeting the 2021 systolic blood pressure goal rose from 18.3% in 2020 to 21.9% in 2024, an absolute difference of 3.6 percentage points (95% CI 1.9-5.3). Mean antihypertensive use changed from 1.53 to 1.55 drugs over the same period, suggesting little change in treatment intensity after guideline publication.

Within the longitudinal cohort, 19.8% of patients were within the KDIGO target at index date. Systolic blood pressure above target was associated with higher CVD risk, HR 1.19 (95% CI 1.11-1.27); higher kidney failure risk, HR 1.21 (95% CI 1.08-1.35); and lower hypotension risk, HR 0.80 (95% CI 0.72-0.89). No reported differences were seen in syncope, bradycardia, electrolyte abnormalities, or injurious falls.

According to the investigators' explanation for limited uptake, older age, multiple comorbidities, polypharmacy, concern about harms, and the practical difficulty of standardized blood pressure measurement in routine care may all have contributed to low adoption. Additional methodological detail on adjustment and blood pressure measurement workflow was not available here. These findings support a description of limited routine uptake, while the longitudinal comparisons remain observational associations rather than causal effects.

The study authors reported that adoption of the 2021 KDIGO systolic blood pressure target in stage 3 to 4 CKD remained limited across the years after guideline publication. In the longitudinal cohort, blood pressure above target tracked with higher cardiovascular and kidney failure risk.

Clinician Questions

Which patients were included in the real-world CKD blood pressure adoption analyses?

The analyses covered adults with stage 3 or 4 CKD receiving care in the Mass General Brigham network, with serial annual cross-sections from 2020 through 2024 and a separate longitudinal cohort of incident stage 3 or 4 CKD identified from 2014 through 2019. The findings therefore apply to routine-care populations within one U.S. health system rather than to a trial population assembled under standardized research conditions.

How did the KDIGO systolic BP target differ from the ACC/AHA target discussed in CKD?

KDIGO set a lower systolic target and linked it to standardized blood pressure measurement as in SPRINT, whereas the ACC/AHA threshold discussed in the source was less intensive and framed around routine clinical practice, where measurements are often nonstandardized.

What safety outcomes were examined when systolic BP was above the KDIGO target in CKD?

The longitudinal analysis evaluated hypotension, syncope, bradycardia, electrolyte abnormalities, and injurious falls. Blood pressure above target was linked to lower hypotension risk, while no reported differences were seen in the other named safety outcomes.

Recommended Reading

• For more on BP treatment in CKD: Finerenone Associated with Lowered BP in T2D and DKD