Cardiovascular Implications of 2021 KDIGO Blood Pressure Guideline

Quick Takes

  • The proportions of CKD patients requiring BP-lowering treatment were 53.7% per the 2012 KDIGO guideline, 60.4% per the 2017 ACC/AHA guideline, and 66.1% per the 2021 KDIGO guideline.
  • These data suggest that intensive BP control to a lower target of systolic <120 mm Hg may bestow additional benefits to those with CKD.
  • Additional studies are indicated to define whether incremental benefits can be achieved with intensive control of diastolic BP when the 2021 KDIGO systolic BP target is met.

Study Questions:

What are the potential implications of the 2021 Kidney Disease: Improving Global Outcomes (KDIGO) blood pressure (BP) target, compared with the 2012 KDIGO and 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP targets, as related to cardiovascular disease (CVD) outcomes?

Methods:

The investigators identified and categorized adults with nondialysis chronic kidney disease (CKD) from the cross-sectional Korea National Health and Nutrition Examination Survey (KNHANES) and longitudinal National Health Insurance Service (NHIS) data into four groups based on concordance/discordance between guidelines: 1) above both targets, 2) above 2021 KDIGO only, 3) above 2012 KDIGO or 2017 ACC/AHA only, and 4) controlled within both targets. The authors determined the nationally representative proportion and CVD risk of each group. Hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) of the outcomes for each BP status were calculated with the use of cause-specific Cox proportional hazards models, in which the participants were censored at competing death events (i.e., noncardiovascular death for composite CVD event, nonkidney and noncardiovascular death for composite cardiokidney event, and all-cause death for nonfatal outcomes).

Results:

In KNHANES (n = 1,939), 50.2% had BP above both 2021 and 2012 KDIGO targets, 15.9% above the 2021 KDIGO target only, 3.5% above the 2012 KDIGO target only, and 30.4% controlled within both targets. In NHIS (n = 412,167; median follow-up, 10.0 years), multivariable-adjusted hazard ratios for CVD events were 1.52 (95% CI, 1.47-1.58) among participants with BP above both targets, 1.28 (95% CI, 1.24-1.32) among those with BP above 2021 KDIGO only, and 1.07 (95% CI, 0.61-1.89) among those with BP above 2012 KDIGO only, compared to those with BP controlled within both targets. Results were similar for comparison between 2021 KDIGO and 2017 ACC/AHA BP targets.

Conclusions:

The authors reported that new candidates for BP-lowering treatment per the 2021 KDIGO guideline account for a substantial proportion of the total CKD population and bear significantly high CVD risk.

Perspective:

This analysis of Korean nationwide cross-sectional and longitudinal data reports that the proportions of CKD patients requiring BP-lowering treatment were 53.7% per the 2012 KDIGO guideline, 60.4% per the 2017 ACC/AHA guideline, and 66.1% per the 2021 KDIGO guideline. Of note, participants who had BP above the 2021 KDIGO target (i.e., systolic BP >120 mm Hg) exhibited a significantly higher CVD risk regardless of whether the other (2012 KDIGO or 2017 ACC/AHA) target was met or not. Overall, these data suggest that intensive BP control to a lower target of systolic <120 mm Hg may bestow additional benefits to those with CKD. Additional studies are indicated to define whether incremental benefits can be achieved with intensive control of diastolic BP when the 2021 KDIGO systolic BP target is met.

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention, Hypertension

Keywords: Antihypertensive Agents, Blood Pressure, Cardiovascular Diseases, Hypertension, Kidney Diseases, Metabolic Syndrome, National Health Programs, Primary Prevention, Renal Insufficiency, Chronic, Risk, Vascular Diseases


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