volume 2 | issue 5 | DECEMBER 2012 http://www.kidney-international.org Official Journal of the International Society of Nephrology KDIGOClinicalPracticeGuidelinefortheManagementofBloodPressure inChronicKidneyDisease KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease KDIGO gratefully acknowledges the following consortium of sponsors that make our initiatives possible: Abbott, Amgen, Bayer Schering Pharma, Belo Foundation, Bristol-Myers Squibb, Chugai Pharmaceutical, Coca-Cola Company, Dole Food Company, Fresenius Medical Care, Genzyme, Hoffmann-LaRoche, JC Penney, Kyowa Hakko Kirin, NATCO The Organization for Transplant Professionals, NKF-Board of Directors, Novartis, Pharmacosmos, PUMC Pharmaceutical, Robert and Jane Cizik Foundation, Shire, Takeda Pharmaceutical, Transwestern Commercial Services, Vifor Pharma, and Wyeth. Sponsorship Statement: KDIGO is supported by a consortium of sponsors and no funding is accepted for the development of specific guidelines. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease Tables v KDIGO Board Members vi Reference Keys vii Abbreviations and Acronyms viii Notice Foreword Work Group Membership Abstract Summary of Recommendation Statements Chapter 1: Introduction Chapter 2: Lifestyle and pharmacological treatments for lowering blood pressure in CKD ND patients Chapter 3: Blood pressure management in CKD ND patients without diabetes mellitus Chapter 4: Blood pressure management in CKD ND patients with diabetes mellitus Chapter 5: Blood pressure management in kidney transplant recipients (CKD T) Chapter 6: Blood pressure management in children with CKD ND Chapter 7: Blood pressure management in elderly persons with CKD ND Chapter 8: Future directions and controversies Methods for Guideline Development Biographic and Disclosure Information Acknowledgments References http://www.kidney-international.org contents & 2012 KDIGO VOL 2 | ISSUE 5 | DECEMBER 2012 TABLES Table 1. Relationship among categories for albuminuria and proteinuria Table 2. Selected calcium-channel blockers Table 3. Questions for future research Table 4. Existing guidelines on ambulatory BP monitoring (ABPM) and home BP monitoring Table 5. Systematic review topics and screening criteria Table 6. Hierarchy of outcomes Table 7. Relevant systematic reviews and meta-analyses Table 8. Literature yield Table 9. Work products for BP guideline Table 10. Classification of study quality Table 11. GRADE system for grading quality of evidence Table 12. Final grade for overall quality of evidence Table 13. Balance of benefits and harms Table 14. KDIGO nomenclature and description for grading recommendations Table 15. Determinants of strength of recommendation Table 16. Existing major guidelines and recommendations on hypertension and anti-hypertensive agents in CKD Table 17. The Conference on Guideline Standardization (COGS) checklist for reporting clinical practice guidelines Additional information in the form of supplementary materials can be found online at http://www.kdigo.org/clinical_practice_guidelines/bp.php http://www.kidney-international.org contents & 2012 KDIGO Kidney International Supplements (2012) 2, v v KDIGO Board Members Garabed Eknoyan, MD Norbert Lameire, MD, PhD Founding KDIGO Co-Chairs Kai-Uwe Eckardt, MD Immediate Past Co-Chair Bertram L Kasiske, MD KDIGO Co-Chair David C Wheeler, MD, FRCP KDIGO Co-Chair Omar I Abboud, MD, FRCP Sharon Adler, MD, FASN Rajiv Agarwal, MD Sharon P Andreoli, MD Gavin J Becker, MD, FRACP Fred Brown, MBA, FACHE Daniel C Cattran, MD, FRCPC Allan J Collins, MD, FACP Rosanna Coppo, MD Josef Coresh, MD, PhD Ricardo Correa-Rotter, MD Adrian Covic, MD, PhD Jonathan C Craig, MBChB, MM (Clin Epi), DCH, FRACP, PhD Angel de Francisco, MD Paul de Jong, MD, PhD Ana Figueiredo, RN, MSc, PhD Mohammed Benghanem Gharbi, MD Gordon Guyatt, MD, MSc, BSc, FRCPC David Harris, MD Lai Seong Hooi, MD Enyu Imai, MD, PhD Lesley A Inker, MD, MS, FRCP Michel Jadoul, MD Simon Jenkins, MBE, FRCGP Suhnggwon Kim, MD, PhD Martin K Kuhlmann, MD Nathan W Levin, MD, FACP Philip K-T Li, MD, FRCP, FACP Zhi-Hong Liu, MD Pablo Massari, MD Peter A McCullough, MD, MPH, FACC, FACP Rafique Moosa, MD Miguel C Riella, MD Adibul Hasan Rizvi, MBBS, FRCP Bernardo Rodriquez-Iturbe, MD Robert Schrier, MD Justin Silver, MD, PhD Marcello Tonelli, MD, SM, FRCPC Yusuke Tsukamoto, MD Theodor Vogels, MSW Angela Yee-Moon Wang, MD, PhD, FRCP Christoph Wanner, MD Elena Zakharova, MD, PhD NKF-KDIGO GUIDELINE DEVELOPMENT STAFF Kerry Willis, PhD, Senior Vice-President for Scientific Activities Michael Cheung, MA, Guideline Development Director Sean Slifer, BA, Guideline Development Manager Kidney International Supplements (2012) 2, vi vi http://www.kidney-international.org & 2012 KDIGO CONVERSION FACTORS OF METRIC UNITS TO SI UNITS Parameter Metric units Conversion factor SI units Blood urea nitrogen mg/ml 0.357 mmol/l Creatinine (serum) mg/dl 88.4 mmol/l Creatinine clearance ml/min 0.01667 ml/s Note: Metric unit  conversion factor SI unit. Grade Quality of evidence Meaning A High We are confident that the true effect lies close to that of the estimate of the effect. B Moderate The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. C Low The true effect may be substantially different from the estimate of the effect. D Very low The estimate of effect is very uncertain, and often will be far from the truth. CURRENT CHRONIC KIDNEY DISEASE (CKD) NOMENCLATURE USED BY KDIGO CKD categories Definition CKD CKD of any stage (1 5), with or without a kidney transplant, including both non-dialysis dependent CKD (CKD 1 5 ND) and dialysis-dependent CKD (CKD 5D) CKD ND Non-dialysis-dependent CKD of any stage (1 5), with or without a kidney transplant (i.e., CKD excluding CKD 5D) CKD T Non-dialysis-dependent CKD of any stage (1 5) with a kidney transplant Specific CKD Stages CKD 1, 2, 3, 4 Specific stages of CKD, CKD ND, or CKD T CKD 3-4, etc. Range of specific stages (e.g., both CKD 3 and CKD 4) CKD 5D Dialysis-dependent CKD 5 CKD 5HD Hemodialysis-dependent CKD 5 CKD 5PD Peritoneal dialysis-dependent CKD 5 Implications Grade* Patients Clinicians Policy We recommend Most people in your situation would want the recommended course of action and only a small proportion would not. Most patients should receive the recommended course of action. The recommendation can be evaluated as a candidate for developing a policy or a performance measure. We suggest The majority of people in your situation would want the recommended course of action, but many would not. Different choices will be appropriate for different patients. Each patient needs help to arrive at a management decision consistent with her or his values and preferences. The recommendation is likely to require substantial debate and involvement of stakeholders before policy can be determined. *The additional category Not Graded was used, typically, to provide guidance based on common sense or where the topic does not allow adequate application of evidence. The most common examples include recommendations regarding monitoring intervals, counseling, and referral to other clinical specialists. The ungraded recommendations are generally written as simple declarative statements, but are not meant to be interpreted as being stronger recommendations than Level 1 or 2 recommendations. NOMENCLATURE AND DESCRIPTION FOR RATING GUIDELINE RECOMMENDATIONS Within each recommendation, the strength of recommendation is indicated as Level 1, Level 2, or Not Graded, and the quality of the supporting evidence is shown as A, B, C, or D. Reference Keys CKD Stage Description GFR (ml/min per 1.73 m2 ) 1 Kidney damage with normal or increased GFR Z90 2 Kidney damage with mild decreased GFR 60 89 3 Moderate decreased GFR 30 59 4 Severe decreased GFR 15 29 Kidney failure o15 (or dialysis) CKD, chronic kidney disease; GFR, glomerular filtration rate. CKD 1 5T notation applies to kidney transplant recipients. a 5D if dialysis (HD or PD). STAGES OF CHRONIC KIDNEY DISEASE Kidney International Supplements (2012) 2, vii vii http://www.kidney-international.org & 2012 KDIGO Kidney International Supplements (2012) 2, viii viii Abbreviations and Acronyms AASK African American Study of Kidney Disease and Hypertension ABCD Appropriate Blood Pressure Control in Diabetes ABPM Ambulatory blood pressure monitoring ACCF American College of Cardiology Foundation ACCORD Action to Control Cardiovascular Risk in Diabetes ACE-I Angiotensin-converting enzyme inhibitor ACR Albumin/creatinine ratio ADVANCE Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation AER Albumin excretion rate AGREE Appraisal of Guidelines for Research and Evaluation AHA American Heart Association ALLHAT Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ALTITUDE Aliskiren Trial in Type 2 Diabetes Using Cardio- vascular and Renal Disease Endpoints ARB Angiotensin-receptor blocker BMI Body mass index BP Blood pressure CAD Coronary artery disease CASE J Candesartan Antihypertensive Survival Evaluation in Japan CI Confidence interval CKD Chronic kidney disease CKD-EPI CKD Epidemiology Collaboration CKD ND Non dialysis-dependent CKD of any stage CKD T Non dialysis-dependent CKD of any stage with a kidney transplant CKD 5D Dialysis-dependent CKD 5 CKiD Chronic Kidney Disease in Children CNI Calcineurin inhibitor COGS Conference on Guideline Standardization CPG Clinical practice guideline CRIC Chronic Renal Insufficiency Cohort CVD Cardiovascular disease DCCT/EDIC Diabetes Control and Complications Trial/Epide- miology of Diabetes Interventions and Complications DRI Direct renin inhibitor EDC Pittsburgh Epidemiology of Diabetes Complica- tions Study ERT Evidence review team ESCAPE Effect of Strict Blood Pressure Control and ACE- Inhibition on Progression of Chronic Renal Failure in Pediatric Patients EUROPA European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease FDA Food and Drug Administration GFR Glomerular filtration rate GRADE Grading of Recommendations Assessment, Development and Evaluation HOPE Heart Outcomes Prevention Evaluation HOT Hypertension Optimal Treatment HR Hazard ratio HYVET Hypertension in the Very Elderly Trial ICD International Classification of Diseases IDNT Irbesartan Diabetic Nephropathy Trial INVEST International Verapamil SR Trandolapril study JATOS Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients JNC Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure KDIGO Kidney Disease: Improving Global Outcomes KDOQI Kidney Disease Outcomes Quality Initiative KEEP Kidney Early Evaluation Program MAP Mean arterial pressure MDRD Modification of Diet in Renal Disease MRFIT Multiple Risk Factor Intervention trial mTOR Mammalian target of rapamycin NHANES National Health and Nutrition Examination Survey NICE National Institute for Health and Clinical Excellence NIH National Institutes of Health NKF National Kidney Foundation NSAID Nonsteroidal anti-inflammatory drug ONTARGET Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint trial PCR Protein/creatinine ratio PEACE Prevention of Events with Angiotensin-Convert- ing Enzyme Inhibitor Therapy PREVEND IT Prevention of Renal and Vascular Endstage Disease Intervention Trial PROGRESS Perindopril Protection Against Recurrent Stroke Study RAAS Renin-angiotensin-aldosterone system RCT Randomized controlled trial REIN-2 Ramipril Efficacy in Nephropathy 2 RENAAL Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan RR Relative risk SCr Serum creatinine SD Standard deviation SECRET Study on Evaluation of Candesartan Cilexetil after Renal Transplantation SHEP Systolic Hypertension in the Elderly Program SPRINT Systolic Blood Pressure Intervention Trial Steno-2 Intensified Multifactorial Intervention in Patients With Type 2 Diabetes and Microalbuminuria STONE Shanghai Trial of Nifedipine in the Elderly Syst-Eur Systolic Hypertension in Europe TRANSCEND Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease UKPDS United Kingdom Prospective Diabetes Study VALISH Valsartan in Elderly Isolated Systolic Hypertension WHO World Health Organization http://www.kidney-international.org & 2012 KDIGO Notice SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE This Clinical Practice Guideline document is based upon systematic literature searches last conducted in January 2011, supplemented with additional evidence through February 2012. It is designed to provide information and assist decision making. It is not intended to define a standard of care, and should not be construed as one, nor should it be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every health-care professional making use of these recommendations is responsible for evaluating the appropriateness of applying them in any particular clinical situation. The recommendations for research contained within this document are general and do not imply a specific protocol. SECTION II: DISCLOSURE Kidney Disease: Improving Global Outcomes (KDIGO) makes every effort to avoid any actual or reasonably perceived conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the Work Group. All members of the Work Group are required to complete, sign, and submit a disclosure and attestation form showing all such relationships that might be perceived or actual conflicts of interest. This document is updated annually and information is adjusted accordingly. All reported information is published in its entirety at the end of this document in the Work Group members Biographic and Disclosure Information section, and is kept on file at the National Kidney Foundation (NKF), Managing Agent for KDIGO. http://www.kidney-international.org & 2012 KDIGO Copyright &2012 by KDIGO. All rights reserved. Single photocopies may be made for personal use as allowed by national copyright laws. Special rates are available for educational institutions that wish to make photocopies for non-profit educational use. No part of this publication may be reproduced, amended, or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without explicit permission in writing from KDIGO. Details on how to seek permission for reproduction or translation, and further information about KDIGO s permissions policies can be obtained by contacting Danielle Green, KDIGO Managing Director, at danielle.green@kdigo.org To the fullest extent of the law, neither KDIGO, Kidney International Supplements, National Kidney Foundation (KDIGO Managing Agent) nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Foreword It is our hope that this document will serve several useful purposes. Our primary goal is to improve patient care. We hope to accomplish this, in the short term, by helping clinicians know and better understand the evidence (or lack of evidence) that determines current practice. By providing comprehensive evidence-based recommendations, this guideline will also help define areas where evidence is lacking and research is needed. Helping to define a research agenda is an often neglected, but very important, function of clinical practice guideline development. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to rate the quality of evidence and the strength of recommendations. In all, there were no recommendations in this guideline for which the overall quality of evidence was graded A, whereas 4 (23.5%) were graded B, 3 (17.7%) were graded C, and 10 (58.8%) were graded D. Although there are reasons other than quality of evidence that underpin a grade 1 or 2 recomm- endation, in general, there is a correlation between the quality of overall evidence and the strength of the recommendation. Thus, there were 8 (47.1%) recommendations graded 1 and 9 (52.9%) graded 2. There were no recommendations graded were 1D. There were no recommendations graded 2A or 2B, 4 (19.1%) statements that were not graded. Some argue that recommendations should not be made when evidence is weak. However, clinicians still need to make decisions in their daily practice, and they often ask, What do the experts do in this setting? We opted to give guidance, rather than remain silent. These recommendations are often rated with a low strength of recommendation and a low quality of evidence, or were not graded. It is important for the users of this guideline to be cognizant of this (see Notice). In every case these recommendations are meant to be a place for clinicians to start, not stop, their inquiries into specific management questions pertinent to the patients they see in daily practice. We wish to thank Dr Gavin Becker who co-chaired the Work Group with David Wheeler, along with all of the Work Group members who volunteered countless hours of their time developing this guideline. We also thank the Evidence Review Team members and staff of the National Kidney Foundation who made this project possible. Finally, we owe a special debt of gratitude to the many KDIGO Board members and individuals who volunteered time reviewing the guide- line, and making very helpful suggestions. Bertram L Kasiske, MD David C Wheeler, MD, FRCP KDIGO Co-Chair KDIGO Co-Chair http://www.kidney-international.org & 2012 KDIGO Work Group Membership http://www.kidney-international.org & 2012 KDIGO WORK GROUP CO-CHAIRS Gavin J Becker, MD, FRACP Royal Melbourne Hospital Melbourne, Australia David C Wheeler, MD, FRCP University College London London, United Kingdom WORK GROUP Dick de Zeeuw, MD, PhD University Medical Center Groningen Groningen, Netherlands Toshiro Fujita, MD University of Tokyo School of Medicine Tokyo, Japan Susan L Furth, MD, PhD The Children s Hospital of Philadelphia Philadelphia, PA, USA Hallvard Holdaas, MD, PhD Hospital Rikshospitalet Oslo, Norway Shanthi Mendis, MBBS, MD, FRCP, FACC World Health Organization Geneva, Switzerland Suzanne Oparil, MD University of Alabama Birmingham, AL, USA Vlado Perkovic, MBBS, FRACP, FASN, PhD George Institute for International Health Sydney, Australia Cibele Isaac Saad Rodrigues, MD, PhD Catholic University of Sa o Paulo Sa o Paulo, Brazil Mark J Sarnak, MD, MS Tufts Medical Center Boston, MA, USA Guntram Schernthaner, MD Rudolfstiftung Hospital Vienna, Austria Charles R V Tomson, DM, FRCP Southmead Hospital Bristol, United Kingdom Carmine Zoccali, MD CNR-IBIM Clinical Research Unit, Ospedali Riuniti Reggio Calabria, Italy EVIDENCE REVIEW TEAM Tufts Center for Kidney Disease Guideline Development and Implementation, Tufts Medical Center, Boston, MA, USA: Katrin Uhlig, MD, MS, Project Director; Director, Guideline Development Ashish Upadhyay, MD, Assistant Project Director Amy Earley, BS, Project Coordinator Shana Haynes, MS, DHSc, Research Assistant Jenny Lamont, MS, Project Manager In addition, support and supervision were provided by: Ethan M Balk, MD, MPH; Program Director, Evidence Based Medicine Abstract The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease aims to provide guidance on blood pressure management and treatment for all non-dialysis-dependent CKD patients and kidney transplant recipients. Guideline development followed an explicit process of evidence review and appraisal. Treatment approaches are addressed in each chapter and guideline recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the GRADE approach. Ongoing areas of controversies and limitations of the evidence are discussed and additional suggestions are also provided for future research. Keywords: blood pressure; chronic kidney disease; clinical practice guideline; evidence-based recommendation; KDIGO; systematic review CITATION In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney inter., Suppl. 2012; 2: 337 414. http://www.kidney-international.org & 2012 KDIGO Summary of Recommendation Statements http://www.kidney-international.org & 2012 KDIGO Chapter 2: Lifestyle and pharmacological treatments for lowering blood pressure in CKD ND patients GENERAL STRATEGIES 2.1: Individualize BP targets and agents according to age, co-existent cardiovascular disease and other co-morbidities, risk of progression of CKD, presence or absence of retinopathy (in CKD patients with diabetes) and tolerance of treatment. (Not Graded) 2.2: Inquire about postural dizziness and check for postural hypotension regularly when treating CKD patients with BP-lowering drugs. (Not Graded) LIFESTYLE MODIFICATION 2.3: Encourage lifestyle modification in patients with CKD to lower BP and improve long-term cardiovascular and other outcomes: 2.3.1: We recommend achieving or maintaining a healthy weight (BMI 20 to 25). (1D) 2.3.2: We recommend lowering salt intake to o90 mmol (o2 g) per day of sodium (corresponding to 5 g of sodium chloride), unless contraindicated. (1C) 2.3.3: We recommend undertaking an exercise program compatible with cardiovascular health and tolerance, aiming for at least 30 minutes 5 times per week. (1D) 2.3.4: We suggest limiting alcohol intake to no more than two standard drinks per day for men and no more than one standard drink per day for women. (2D) Chapter 3: Blood pressure management in CKD ND patients without diabetes mellitus 3.1: We recommend that non-diabetic adults with CKD ND and urine albumin excretion o30 mg per 24 hours (or equivalent*) whose office BP is consistently 4140 mm Hg systolic or 490 mm Hg diastolic be treated with BP-lowering drugs to maintain a BP that is consistently r140 mm Hg systolic and r90 mm Hg diastolic. (1B) 3.2: We suggest that non-diabetic adults with CKD ND and urine albumin excretion of 30 to 300 mg per 24 hours (or equivalent*) whose office BP is consistently 4130 mm Hg systolic or 480 mm Hg diastolic be treated with BP-lowering drugs to maintain a BP that is consistently r130 mm Hg systolic and r80 mm Hg diastolic. (2D) 3.3: We suggest that non-diabetic adults with CKD ND and urine albumin excretion 4300 mg per 24 hours (or equivalent*) whose office BP is consistently 4130 mm Hg systolic or 480 mm Hg diastolic be treated with BP-lowering drugs to maintain a BP that is consistently r130 mm Hg systolic and r80 mm Hg diastolic. (2C) 3.4: We suggest that an ARB or ACE-I be used in non-diabetic adults with CKD ND and urine albumin excretion of 30 to 300 mg per 24 hours (or equivalent*) in whom treatment with BP-lowering drugs is indicated. (2D) 3.5: We recommend that an ARB or ACE-I be used in non-diabetic adults with CKD ND and urine albumin excretion 4300 mg per 24 hours (or equivalent*) in whom treatment with BP-lowering drugs is indicated. (1B) *Approximate equivalents for albumin excretion rate per 24 hours expressed as protein excretion rate per 24 hours, albumin/creatinine ratio, protein/ creatinine ratio, and protein reagent strip results are given in Table 1, Chapter 1. Chapter 4: Blood pressure management in CKD ND patients with diabetes mellitus 4.1: We recommend that adults with diabetes and CKD ND with urine albumin excretion o30 mg per 24 hours (or equivalent*) whose office BP is consistently 4140 mm Hg systolic or 490 mm Hg diastolic be treated with BP- lowering drugs to maintain a BP that is consistently r140 mm Hg systolic and r90 mm Hg diastolic. (1B) 4.2: We suggest that adults with diabetes and CKD ND with urine albumin excretion 430 mg per 24 hours (or equivalent*) whose office BP is consistently 4130 mm Hg systolic or 480 mm Hg diastolic be treated with BP- lowering drugs to maintain a BP that is consistently r130 mm Hg systolic and r80 mm Hg diastolic. (2D) 4.3: We suggest that an ARB or ACE-I be used in adults with diabetes and CKD ND with urine albumin excretion of 30 to 300 mg per 24 hours (or equivalent*). (2D) 4.4: We recommend that an ARB or ACE-I be used in adults with diabetes and CKD ND with urine albumin excretion 4300 mg per 24 hours (or equivalent*). (1B) *Approximate equivalents for albumin excretion rate per 24 hours expressed as protein excretion rate per 24 hours, albumin/creatinine ratio, protein/ creatinine ratio, and protein reagent strip results are given in Table 1, Chapter 1. Chapter 5: Blood pressure management in kidney transplant recipients (CKD T) 5.1: We suggest that adult kidney transplant recipients whose office BP is consistently 4130 mm Hg systolic or 480 mm Hg diastolic be treated to maintain a BP that is consistently r130 mm Hg systolic and r80 mm Hg diastolic, irrespective of the level of urine albumin excretion. (2D) 5.2: In adult kidney transplant recipients, choose a BP-lowering agent after taking into account the time after transplantation, use of calcineurin inhibitors, presence or absence of persistent albuminuria, and other co-morbid conditions. (Not Graded) Chapter 6: Blood pressure management in children with CKD ND 6.1: We recommend that in children with CKD ND, BP-lowering treatment is started when BP is consistently above the percentile for age, sex, and height. (1C) 6.2: We suggest that in children with CKD ND (particularly those with proteinuria), BP is lowered to consistently achieve systolic and diastolic readings less than or equal to the 50th percentile for age, sex, and height, unless achieving these targets is limited by signs or symptoms of hypotension. (2D) 6.3: We suggest that an ARB or ACE-I be used in children with CKD ND in whom treatment with BP-lowering drugs is indicated, irrespective of the level of proteinuria. (2D) Chapter 7: Blood pressure management in elderly persons with CKD ND 7.1: Tailor BP treatment regimens in elderly patients with CKD ND by carefully considering age, co-morbidities and other therapies, with gradual escalation of treatment and close attention to adverse events related to BP treatment, including electrolyte disorders, acute deterioration in kidney function, orthostatic hypotension and drug side effects. (Not Graded) summary of recommendation statements Chapter 1: Introduction There is a strong association between chronic kidney disease (CKD) and an elevated blood pressure (BP) whereby each can cause or aggravate the other. BP control is fundamental to the care of patients with CKD and is relevant at all stages of CKD regardless of the underlying cause. Clinical practice guidelines (CPGs) have been published on this topic by many authoritative bodies over the past decade, the most comprehensive being the National Kidney Foundation s (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines on Hypertension and Antihyper- tensive Agents in Chronic Kidney Disease, which was based on evidence collected up to 2001 (http://www.kidney.org/ The Kid- ney Disease: Improving Global Outcomes (KDIGO) Board believed that it would be clinically useful to update this CPG to incorporate the evidence gathered since then. KDIGO therefore commissioned an evidence review to include the recent literature and assembled a Work Group with the mandate of writing an updated guideline relevant to an international audience. This KDIGO Guideline, entitled Management of Blood Pressure in Chronic Kidney Disease, is the result of these efforts. Scope of this guideline This Guideline has been developed to provide advice on the management of BP in patients with non dialysis-dependent CKD (CKD ND) (see Reference Keys). BP. We have avoided using the term hypertension in our title because this implies that there is a BP value above or below which morbidity or mortality changes in a stepwise fashion, hence suggesting that it is possible to set a universal BP target. In reality, it proved difficult to define precise targets appropriate for all CKD subpopulations, consistent with the notion that the ideal BP may differ between patients, once other factors are considered. These factors include specific features of CKD such as the severity of albuminuria or proteinuria, the presence of other risk factors for cardiovascular disease (CVD) and co- morbidities. Another reason for our choice of terminology is that agents introduced primarily to treat high BP may have actions that may not be directly linked to BP-lowering (e.g., the anti-albuminuric effects of angiotensin-converting enzyme inhibitors [ACE-Is] and angiotensin-receptor blockers [ARBs]). Definition of CKD. The Work Group defined CKD according to the standard KDOQI classification system2 as endorsed by KDIGO.3 Populations of interest. The populations covered in this guideline are: K Adults with CKD ND without diabetes mellitus K Adults with CKD ND with diabetes mellitus K Adults with CKD ND who have received a kidney transplant (CKD T) K Children with CKD ND K Elderly with CKD ND The scope of this guideline did not include BP manage- ment in patients with dialysis-dependent CKD 5 (CKD 5D) since this has been the topic of a recent KDIGO consensus and has been covered by two recent systematic There are other groups of patients with CKD for whom specific recommendations might be welcome, but who are not represented in sufficient numbers in randomized controlled trials (RCTs) to constitute a sufficiently robust evidence base. The evidence review team (ERT) was asked to present the evidence separately for adults with CKD and diabetes, since these individuals constitute the single largest subgroup of CKD patients in the world. The separation of the evidence base according to diabetes status meant that there were two separate datasets for the Work Group to review. Although the two sets of recommen- dations had much in common, the Work Group decided that they differed sufficiently in detail to warrant two separate chapters. Adults who received a kidney transplant, children, and the elderly were also thought to deserve dedicated chapters, although the evidence base for each of these subpopulations is rather small. The Work Group was unable to identify sufficient evidence to make recommendations according to severity (stage) of CKD, although common sense dictates that pharmacological management should differ at least between mild CKD (patients with normal glomerular filtration rate [GFR]) and advanced CKD (patients with low GFR). However, the Work Group did consider the modification of drug dosages and risks related to the various classes of BP-lowering agents in the context of CKD in Chapter 2. Clearly there are many other populations that could have been considered. CKD patients with glomerulonephritis are the subject of a recent KDIGO Guideline,7 so they were not considered separately here. Although management of BP in the pregnant CKD patient is an important issue, there is insuf- ficient evidence in this subgroup to allow recommendations to be made.8 Furthermore, the Work Group did not consider the management of BP in patients with acute kidney injury. http://www.kidney-international.org chapter 1 & 2012 KDIGO Interventions. Interventions primarily aiming at modify- ing BP include advice on lifestyle and administration of pharmacological agents that reduce BP. The efficacies of both strategies have been widely studied in the general population with high BP. The pharmacology of anti-hypertensive agents was detailed in the 2004 KDOQI guideline.1 Of the available RCTs that met our inclusion criteria, most involved agents interfering with the renin-angiotensin- aldosterone system (RAAS). Accordingly, these agents may be over-represented in this Guideline, and if so, it is because of the availability of the evidence rather than a deliberate focus by the Work Group. Evidence for interventions Because CKD is common and BP levels are often elevated in CKD populations, the management of BP in CKD patients could have an enormous global impact. Given that the focus of the Guideline is on management and the comparative effectiveness of various interventions, the preferred and most robust evidence is derived from large-scale RCTs which assessed hard clinical outcomes. The ERT was asked to include RCTs with a minimum of 50 patients in each arm and interventions included pharmacological agents (alone or in combination), lifestyle modifications, and trials assessing various levels of BP control. Outcomes of interest were mortality, cardiovascular events and changes in kidney function including urine albumin or protein excretion. Reduction in BP, particularly when achieved using agents that interfere with the RAAS, can lead to acute reductions in kidney function and albuminuria; thus the minimal duration of follow-up in RCTs required for their inclusion in the evidence review was set at 1 year for kidney function, cardi- ovascular outcomes, and mortality and 3 months for urine albumin or protein levels. Because there were so few trials assessing lifestyle modifications, BP reduction was included as an outcome, with the minimum follow-up period set at 6 weeks. The approach to the evidence review is described in detail in Methods for Guideline Development. The ERT conducted a systematic review of RCTs involving individuals with CKD. This was supplemented with published systematic reviews and meta-analyses (which often included smaller RCTs). Work Group members further supplemented this yield with selected RCTs that included individuals at increased risk of CVD but who were not specifically chosen on the basis of having CKD. The Work Group also helped identify RCTs that included CKD subgroups. To a lesser extent, the Work Group made reference to observational evidence from large popula- tion studies where evidence from RCTs was perceived to be insufficient. Not all questions of interest have been the subject of RCTs; some issues do not lend themselves to be studied in this manner. To facilitate further discussion on major issues relevant to management of BP in CKD patients (for which there is some evidence but ongoing controversy remains), the Work Group included a chapter on Future Directions and Controversies (Chapter 8). For other issues widely accepted in practice, but not supported by evidence from RCTs, the Work Group wrote ungraded recommendations reflecting the consensus of its members. These ungraded statements are explained in detail in the accompanying narrative. The Work Group did not wish to provide advice on specific treatment questions for which there was no supporting evidence. By highlighting these gaps in knowl- edge, we aim to promote further research. During the preparation of this Guideline, the Work Group was aware that other international organizations were writing new or updating old guidelines that were potentially relevant to the management of BP in CKD patients. The Work Group kept in contact with these other organizations and sought to achieve consistency with their recommendations as much as possible. Measurement of BP The Work Group recognized that many reviews on the methodology of BP measurement have been published9,10 and that this topic was covered in detail in the 2004 KDOQI Previous publications have highlighted incon- sistencies between conventional office (or clinic) BP measure- ments and other methods, such as self-measurement of BP at home or ambulatory blood pressure monitoring (ABPM).11 13 Many recommendations regarding when and how to use ABPM in hypertensive patients not known to have CKD have also been published. Although few studies have assessed the value of ABPM CKD patients, the small, short-term studies that do exist reflect the inconsistency between office BP measurements and other BP measurements and also suggest that ABPM gives a better indication of overall BP and kidney prognosis than office BP measurements.11 13 Despite this, to date there has only been one large RCT of BP control in CKD patients (all of whom were children) in which ABPM was used as the method for BP assessment.14 We therefore cannot provide evidence-based recommendations regarding the use of ABPM to evaluate BP in CKD patients but existing evidence is reviewed in Chapter 8. Since office BP measurements are used in almost all RCTs of interventions that modify BP in CKD, this Guideline can only make recommendations about BP assessed by this method. Because office readings are known to vary from day to day, management decisions should be based on repeated as emphasized in this guideline by the use of the term consistently (e.g., Recommendation 4.1 y maintain a BP that is consistently r140 mm Hg systolic y). The term is used simply to imply that the BP has been measured more than once and that there was meaningful agreement between the measurements. The Work Group also discussed whether to consider pulse pressure and/or pulse wave velocity, measures of arterial compliance that may provide important prognostic informa- tion in CKD patients. However, there is a paucity of data from RCTs showing that any particular intervention reliably alters these measures and subsequently influences mortality or morbidity. Thus the Work Group was not able to make any evidence-based recommendations relating to these measurements. However, these issues are of interest for the future of BP assessment in CKD patients and are discussed in further detail in Chapter 8. Albuminuria and proteinuria Some BP-lowering agents are particular effective at reducing albuminuria or proteinuria, suggesting that BP management should differ depending on the amount of albumin or protein in the urine.16 19 Accordingly, as in the KDOQI 2004 Guidelines and the majority of other CPGs addressing BP control in patients with CKD or diabetes, the Work Group has attempted to stratify treatment effects according to urinary albumin excretion. Based on a recent KDIGO Controversies Conference and data from the CKD Prognosis Consortium, the Work Group used three categories (levels) Wherever possible, the Work Group modified its recommendations to fit these categories, although since not all RCTs use this classification system, consistency was not achievable. The three categories of urinary albumin excretion are as follows: 4300 mg per 24 h (or macroalbuminuria ), 30 to 300 mg per 24 h (or micro- albuminuria ), and o30 mg per 24 h (Table 1). When other measures (such as assessment of proteinuria, ratios of urinary albumin or urinary protein to urine creatinine, or protein reagent strip readings) were used in RCTs, these measures were translated to albumin excretion rates (AERs) per 24 h, recognizing that these converted values are approximations at best. Recommendations and suggestions for interventions based on albumin levels expressed in milligrams per 24 h can also be converted (Table 1). BP thresholds and targets Perhaps the most important questions for health care professionals are first, at what BP level should BP-lowering strategies be introduced in CKD patients (i.e., what is the BP treatment threshold?), and second, what BP levels should be aimed for (i.e., what is the BP treatment target?). Although the evidence base for the BP treatment threshold differs from the evidence base for the BP target, we could not find a robust justification to recommend different BP levels for these two parameters. Doing so might also lead to confusion, since we would be recommending two different BP levels possibly with two evidence ratings and would not be able to provide coherent advice for managing patients between the recommended threshold and target BPs. Studies that have not specifically targeted CKD patients demonstrate that BP is a continuous risk factor for CVD BP targets could differ depending on the presence of other CVD risk factors in each patient. This approach contrasts with the one size fits all philosophy that has previously been endorsed. There are far less data in CKD patients to inform the best approach. In RCTs involving CKD patients who are randomized to different BP targets, the achieved differences between groups are usually less than the targeted differences. Intention-to-treat analyses allow con- clusions to be drawn based on target BP levels rather than achieved BP levels. The Work Group generally followed this convention and based recommendations on target levels BP levels rather than those achieved in the RCTs. It also considered the evidence derived from RCTs in which patients were not randomized to BP targets but achieved BPs were reported. The logic for using target BP levels in RCTs rather than the achieved BP levels observed as the basis for setting guideline targets has been questioned;22 this concern is one reason for our conservative approach to BP target setting in this Guideline. Outcomes The major outcomes relevant to BP control in CKD patients are kidney disease progression and cardiovascular events (including stroke). Kidney outcomes. Although it is possible for a diagnosis of CKD to be made in an individual with a normal GFR and AER and even a normal BP (for example on the basis of an imaging study, as in early adult polycystic kidney disease), most patients recruited into RCTs addressing BP and its management in CKD have a reduced GFR or persistently elevated albumin excretion. Entry criteria for RCTs involving Table 1 | Relationship among categories for albuminuria and proteinuriaa Categories Measure Normal to mildly increased Moderately increased Severely increased ACR PCR Protein reagent strip Negative to trace Trace to + + or greater ACR, albumin/creatinine ratio; AER, albumin excretion rate; PCR, protein/creatinine ratio, PER, protein excretion rate. Albuminuria and proteinuria can be measured using excretion rates in timed urine collections, ratio of concentrations to creatinine concentration in spot urine samples, and using reagent strips in spot urine samples. Relationships among measurement methods within a category are not exact. The relationships between AER and ACR and between PER and PCR are based on the assumption that average creatinine excretion rate is approximately 1.0 g/24 h or 10 mmol/24 h. The conversions are rounded for pragmatic reasons. (For an exact conversion from mg/g of creatinine to mg/mmol of creatinine, multiply by 0.113.) Creatinine excretion varies with age, sex, race and diet; therefore the relationship among these categories is approximate only. ACR o10 mg/g (o1 mg/mmol) is considered normal; ACR 10 29 mg/g (1.0 2.9 mg/mmol) is considered high normal. The relationship between urine reagent strip results and other measures depends on urine concentration. a Tentatively adopted by KDIGO CKD Work Group. CKD patients are usually based on these parameters, changes in which may form the basis for kidney end points. Kidney function. Changes in kidney function are impor- tant outcomes in clinical trials assessing the effects of various BP-management regimens in CKD patients. Although the most important events are the requirement for renal replacement therapy or death due to kidney failure, many studies have used surrogates such as changes in GFR or the percentage of patients in whom the serum creatinine (SCr) level doubles. Such numerical end points may be particularly relevant in trials that include patients with early-stage CKD, among whom kidney failure and death are uncommon events. One problem with the assessment of such surrogates is that the therapeutic agent used to modify BP may also directly alter kidney function. For example, ACE-Is are known to reduce GFR through a vasodilator effect on the efferent arteriole. This effect may be beneficial in the early stages of CKD when a reduced intra-glomerular pressure is protective, but might be detrimental at a later stage when kidney function is severely compromised and dialysis may be imminent, at which time GFR may increase if ACE-Is are Thus, a drug may modify GFR via a mechanism that does not directly involve changes in systemic BP and the impact of this effect on the patient may vary according to CKD stage. The Work Group bore such considerations in mind when assessing the evidence and viewed consistency in the change of GFR outcomes across various CKD stages as a strong indicator of the benefits of a particular agent on kidney function. Albuminuria. The level of albuminuria in CKD predicts not only the prognosis with respect to kidney function but also morbidity and mortality from CVD events including Urinary albumin excretion is influenced by BP and by many of the agents used to reduce BP, particularly ACE-Is and ARBs. The concept of using albuminuria as a surrogate marker for CKD progression and CVD outcomes is widely accepted, with the reduction of urine albumin levels often being regarded as a target for therapy. This would mean that treatment would be escalated to reduce albuminuria to a preferred level, regardless of BP. Treating to an albumin target usually involves an escalation of RAAS blockade, which can be achieved by restricting dietary salt intake, increasing doses of an ACE-I or an ARB, combining the two classes of medication, or by adding a thiazide diuretic, an aldosterone- receptor blocker or a direct renin inhibitor (DRI). While a strong case has been made for targeting a reduction of albuminuria, particularly with agents that interfere with the RAAS, there have been no large studies in CKD patients reporting long term differences in GFR or CVD outcomes where reduction in urinary albumin levels (regardless of BP) was the primary objective. There is also uncertainty as to whether the dose of a particular agent that is required to achieve BP control is necessarily the same as the dose required for albuminuria reduction.24 The Work Group thus decided that it was premature to recommend an albuminuria reduction target strategy for all cases of CKD but felt this deserved further discussion in Chapter 8. Cardiovascular outcomes. Recognition that premature CVD is a major cause of death in CKD has led to CVD risk management becoming a recognized component of the care of the CKD patient. In planning appropriate interven- tions, one strategy is simply to extrapolate data from CVD outcomes trials in the general population. This approach has been challenged because the benefits of interventions predicted in observational studies25 are not always observed in RCTs involving CKD patients.26,27 In CKD-ND patients,28 unlike CKD patients on dialysis (CKD 5D),29 a higher BP is generally associated with a higher CVD risk, making BP- lowering an attractive goal in an effort to reduce cardiovas- cular morbidity and mortality. Although no RCTs assessing BP lowering agents have been specifically designed or powered to assess cardiovascular event rates as the primary outcome in any group of CKD patients, several studies assessing cardiovascular outcomes have included CKD patients and this information was considered in making the recommendations. Intended Users of this Guideline This Guideline is primarily aimed at health care professionals caring for individuals with CKD, including nephrologists, nurses, and pharmacists, as well as at physicians involved in the care of patients with diabetes and primary care providers. The Guideline is not aimed at health care administrators, policy makers, or regulators, although the explanatory text might be of value to these groups and assist in enhancing implementation and adherence to BP-lowering strategies. The Guideline is also not designed to be used in the development of clinical performance measures. Some of the difficulties in implementation and in auditing BP target achievement are discussed in Chapter 8. DISCLAIMER While every effort is made by the publishers, editorial board, and ISN to see that no inaccurate or misleading data, opinion or statement appears in this Journal, they wish to make it clear that the data and opinions appearing in the articles and advertisements herein are the responsibility of the contribu- tor, copyright holder, or advertiser concerned. Accordingly, the publishers and the ISN, the editorial board and their respective employers, office and agents accept no liability whatsoever for the consequences of any such inaccurate or misleading data, opinion or statement. While every effort is made to ensure that drug doses and other quantities are presented accurately, readers are advised that new methods and techniques involving drug usage, and described within this Journal, should only be followed in conjunction with the drug manufacturer s own published literature. Chapter 2: Lifestyle and pharmacological treatments for lowering blood pressure in CKD ND patients INTRODUCTION This section outlines lifestyle and pharmacological methods to reduce BP in patients with non-dialysis-dependent CKD (CKD ND). Because these strategies were covered in detail in the 2004 KDOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease (http:// www.kidney.org/professionals/KDOQI/guidelines_bp/index. we concentrate on issues relating to BP control in CKD patients that have arisen since 2004. Additional information that may be of help to the clinician (although not specifically relevant to CKD patients) can be found in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) (http://www.nhlbi.nih.gov/guidelines/hypertension/ GENERAL STRATEGIES It is generally accepted that a stepwise combination of lifestyle modifications and drug therapy should be used to lower BP in CKD patients, with escalation of efforts depending on factors such as the severity of the BP elevation, the co-morbidities present and the age of the patient. 2.1: Individualize BP targets and agents according to age, co-existent cardiovascular disease and other co- morbidities, risk of progression of CKD, presence or absence of retinopathy (in CKD patients with diabetes) and tolerance of treatment. (Not Graded) RATIONALE We recognize that individual decision making is required regarding BP targets and agents with the risks and benefit being taken into consideration; however, since there is little evidence from RCTs to guide these decisions, this recom- mendation has not been graded. The potential benefits of lower BP include a decreased risk of both CVD and progression of CKD. To assess the likely benefit in a given patient, the clinician needs to consider such issues as the prior rate of CKD progression, the expected course of the specific disease, the level of urinary albumin excretion and the presence or absence of other risks of CVD. Potential adverse effects generic to treatment used to lower BP include decreases in cerebral perfusion (contributing to dizziness, confusion and falls) and acute deterioration in kidney function. It is widely acknowledged that achievement of a reduction in BP can be difficult in CKD patients, particularly in the elderly, those with co-morbidities, and those with diabetes Increased conduit-artery stiffness, resulting in high pulse pressure (with high systolic and low diastolic pressures) is common in CKD patients, the elderly and patients with diabetes.31 36 Arterial stiffening is associated with an increased risk of CVD independent of other recognized risk factors.37 39 With a high pulse pressure, efforts to reduce systolic BP in older patients and those with coronary artery disease (CAD) can result in lowering diastolic BP to levels well below diastolic targets, which may be associated with greater morbidity or mortality.40,41 A J-shaped relationship between achieved BP and outcome has been observed in the elderly and in patients with vascular disease, possibly suggesting that BP can be reduced too far in Discussion of this issue is further elaborated in Chapters 7 and 8. Unfortunately, in CKD patients, the available evidence proved to be insufficient to allow the Work Group to define the lowest BP targets (see Chapter 8). Similarly, when considering the choice of BP-lowering agents, decision making should be tailored to the individual patient. For instance, ACE-Is and ARBs are potentially harmful in the presence of significant renovascular disease or volume depletion, or when used in combination with nonsteroidal anti-inflammatory drugs (NSAIDs) or cycloox- ygenase-2 (COX-2) inhibitors (as outlined later in this chapter). The presence of diabetic retinopathy in a CKD patient may also influence BP target and choice of agent as outlined in Chapter 4. Based on these considerations, the Work Group concluded that it is good clinical practice to assess the risks and benefits of BP-lowering treatment in an individual patient and to tailor therapy accordingly. 2.2: Inquire about postural dizziness and check for postural hypotension regularly when treating CKD patients with BP-lowering drugs. (Not Graded) RATIONALE Patients with CKD, particularly the elderly31 and diabetic patients with autonomic neuropathy, are prone to orthostatic which may be exacerbated by volume depletion. Many CKD patients will require combinations of drugs to control BP including vasodilators, which can cause or exacerbate postural hypotension. This can lead to postural dizziness, reduced adherence and in extreme cases, syncope http://www.kidney-international.org chapter 2 & 2012 KDIGO or falls with consequent injury. Accordingly, it is sensible to regularly check for symptoms of postural dizziness and to compare lying, sitting and standing BP in CKD patients, particularly before and after altering the treatment regimen. LIFESTYLE MODIFICATION The impact of lifestyle-related factors on BP and the risk of cardiovascular and other diseases have been well documented. A number of observational studies in the general population have linked factors such as salt intake,46 weight and body mass and alcohol intake49 with BP level. RCTs addressing many of these factors have been undertaken, the results of which have led the authors of BP guidelines for the general population9 (e.g., JNC 7) to make specific recommendations about the management of lifestyle as a key component of BP management. Individuals with CKD generally have higher9 BP levels than people with normal kidney function and their BP may be particularly sensitive to some factors related to lifestyle. For example, high salt intake may potentially have a greater impact on BP in patients with CKD than in those without CKD since CKD may reduce the ability to excrete the salt load in the urine. CKD patients may also be more sensitive to harms related to lifestyle interventions; for instance, an individual with tubular disease with salt wasting from the kidney could be at increased risk of hypovolemia if salt intake is restricted. Furthermore, some potential lifestyle interventions, such as increased physical exercise, may be difficult for patients with CKD owing to reduced energy levels. Lifestyle modification offers the potential to lower BP in a simple, inexpensive, effective fashion while also improving a range of other outcomes (e.g., changes in lipid levels resulting from diet and exercise and liver function through moderation of alcohol intake). Because lifestyle changes are applicable to the general population and are potentially implementable at low expense worldwide, the Work Group felt many were sufficiently important to warrant an evidence grade of level 1, with the strength of the evidence varying in accordance to their potential to do harm in CKD patients. 2.3: Encourage lifestyle modification in patients with CKD to lower BP and improve long-term cardio- vascular and other outcomes: 2.3.1: We recommend achieving or maintaining a RATIONALE K Weight reduction lowers BP in the general population. K Observational studies show that weight-loss strategies reduce BP in CKD patients. K Weight-reduction strategies may result in other health benefits to CKD patients including reduction in urine albumin or protein levels, improved lipid profile and increased insulin sensitivity. The prevalence of obesity is very high in Western countries and is increasing rapidly in developed and developing countries around the world. A strong relationship exists between body weight (usually defined as BMI) and BP levels in the general population.50 52 Compared with a person of normal weight, individuals who are overweight or obese tend to have higher BP levels, abnormalities in a range of other cardiovascular parameters (e.g., dyslipidemia52 ), and an increased risk of cardiovascular events. Weight and BP. A weight-reducing diet has been clearly demonstrated to lower BP in overweight individuals in the general population. A systematic review53 published in 2006 identified 14 trials assessing the effects of dietary modification on BP in the general population, all but two of which assessed the effects of weight reduction in overweight persons. Many of the 14 trials also included other modifications to diet (e.g., increased fruit and vegetable intake and salt reduction) and lifestyle (e.g., increased exercise). Trials were 8 to 52 weeks in duration and mostly included participants with elevated BP levels. The quality of the trials was generally suboptimal. Overall, dietary modification reduced systolic BP by 6.0 mm Hg (95% confidence interval [CI] 3.4 8.6) and diastolic BP by 4.8 mm Hg (95% CI 2.7 6.9). High levels of heterogeneity in the trial results were observed. The available data regarding the effects of weight loss in CKD patients has been systematically reviewed by Nava- neethan et al.54 Only two randomized trials were identified but 11 observational studies were also included. A range of surgical and non-surgical weight-loss interventions were assessed. All interventions, when taken together, resulted in significant reduction in weight among CKD patients. This was associated with a reduction in urinary protein excretion (described in two studies) but no overall effect on the GFR, possibly due to the short term nature of the studies. Effects on BP were not reported in the RCTs, whereas the observational studies reported consistently large, significant reductions in BP compared to baseline with both non- surgical weight loss (weighted mean difference in BP 9.0 mm Hg; 95% CI 3.7 14.2 mm Hg; Po0.0001) as well as surgical weight loss (weighted mean difference, 22.6 mm Hg; 95% CI 19.1 26.2; Po0.0001). Thus, weight loss likely improves BP in patients with CKD, although high-quality RCTs are needed to confirm this finding. Body weight and outcomes. In the general population, overweight and obesity have been clearly shown to be associated with an increased risk of cardiovascular events and A J-curve relationship has been described in many reports, revealing an increased risk in underweight individuals (e.g., those with a BMI o18.5) as well. RCTs have demon- strated that weight loss reduces the incidence of diabetes,55 but any beneficial effects on cardiovascular outcomes or survival remain to be proven. Indeed, a number of RCTs involving use of pharmacological agents to induce weight loss have been stopped early owing to unintended and unanticipated adverse effects of the agent being assessed (e.g., rimonabant and The data are less clear for patients with CKD. Obesity has been proposed as a possible potentiator of CKD progression; however, reliable data remain sparse. Many observational studies have suggested that among patients with advanced CKD who are dialysis-dependent, and particularly hemodia- lysis-dependent, clinical outcomes might actually be better for overweight individuals than for non-overweight indivi- Other studies have reported conflicting results.60 It is possible that these observations are due to reverse causality, with the results driven by underlying malnutrition or inflammation in the lower-weight patients and they may also reflect differences in the proportions of muscle and fat in patients with CKD compared with people without CKD. These data should therefore be interpreted with caution. For overweight individuals, the method used to reduce body weight may be important within the context of CKD. Popular and widely recommended weight-loss diets are commonly high in potassium and protein and may therefore increase risks of hyperkalemia and CKD progression in patients with CKD. As the potential benefits and harms have not been specifically addressed in the CKD population, the use of these diets is not recommended. Overall, the available data suggest that achieving or maintaining a body weight in the healthy range will lead to improved BP levels and better long-term CKD outcomes. This is particularly clear for individuals with CKD stages 1 2. Caution should be exercised in patients with more advanced CKD, because malnutrition may be associated with adverse outcomes. Since a high weight may be protective in CKD 5D patients, there could be risks associated with encourag- ing weight loss in those with advanced CKD. Hence, Recommendation 2.3.1 was graded 1D. 2.3.2: We recommend lowering salt intake to o90 mmol (o2 g) per day of sodium (corresponding to 5 g of sodium chloride), unless contraindicated. (1C) RATIONALE K Lowering salt intake reduces BP in the general population. K In CKD patients with reduced GFR, salt retention is associated with an increase in BP. A relationship between average daily salt intake and BP levels has long been recognized, leading to calls from the World Health Organization (WHO) for salt intake to be restricted to improve BP levels (http://www.who.int/cardiovascular_ Restricting salt intake clearly lowers BP by a moderate amount, as demonstrated in a systematic review of seven trials,53 most of which assessed the impact of restricting salt intake to 4 to 6 g (70 100 mmol). Overall, BP levels were reduced as compared to baseline levels: systolic BP by 4.7 mm Hg (95% CI 2.2 7.2) and diastolic BP by 2.5 mm Hg (95% CI 1.8 3.3). Moderate heterogeneity was observed in the effects on systolic BP, but this was corrected when one outlier trial was excluded. Other systematic reviews including a different group of trials have suggested similar but somewhat smaller benefits.62 Alterations in salt handling are likely to be a significant contributor to elevated BP levels in patients with CKD. Although no large scale long term RCTs of salt restriction in CKD patients were found, there is no reason to believe that BP reductions should not also be observed. Reducing salt intake could have a greater capacity to lower BP in patients with CKD who have salt and water retention and this intervention should be routinely discussed with such individuals. A low-sodium diet has been shown to further reduce BP and urine albumin or protein levels in the short term in patients on ARBs63 66 and may be a consideration for those with high BP who have a poor response to ACE-Is or ARBs. Some forms of CKD may be associated with salt wasting from the kidney. Affected individuals may be at higher than usual risk of volume depletion and electrolyte disturbances potentiated by salt restriction. Volume and electrolyte status should thus be carefully monitored in patients with CKD undergoing salt restriction. Recent studies suggesting that low urinary sodium excretion (hence perhaps low dietary sodium intake) associates with higher mortality in diabetes have yet to be confirmed by others or explained.67,68 Since salt restriction is an inexpensive and important contributor to lowering BP in the generally population worldwide, this intervention was deemed a level 1 recom- mendation. But since the evidence base for CKD patients included only small, short-term RCTs involving special circumstances, Recommendation 2.3.2 was graded 1C. 2.3.3: We recommend undertaking an exercise program compatible with cardiovascular health and toler- ance, aiming for at least 30 minutes 5 times per RATIONALE Increased physical exercise has been linked to a broad range of positive health outcomes through a wide variety of mechanisms. A clear inverse relationship between exercise and average daily BP has been demonstrated by a large volume of previous epidemiological data in the general population, although exercise may lead to modest and acute physiological increases in BP during the time of the activity. The effects of exercise on BP in the context of RCTs have been systematically reviewed in the general population.53 Most of the 21 RCTs included in the review examined the efficacy of 3 to 5 weekly sessions of aerobic exercise lasting 30 to 60 minutes. 