Blood pressure targets in renal disease

There is strong evidence that lower than usual targets are beneficial in renal diseases, but especially in those associated with significant proteinuria. Any limits set are arbitrary, but for example, the current SIGN and NICE guideline levels are:

  • Proteinuria low: ACR<70 or PCR<100 – Target blood pressure <140/90 (NICE suggests 130-139/90)
  • Proteinuria high: ACR>70 or PCR>100: – Target blood pressure <130/80 (NICE suggests 120-129/80)

ACE inhibitors or ARBs should be included in:

  • Patients with urinary ACR>30 or PCR>50
  • Diabetics with microalbuminuria, even in the absence of hypertension

The previous UK CKD guidelines and some US guidance recommended slightly lower targets, and some nephrologists favour these:

  • 130/80 for patients with diabetes mellitus and microalbuminuria (but note that diabetics with microalbuminuria benefit from ACE inhibitors at all levels of blood pressure, including normal levels)
  • 130/80 for non-diabetic patients with chronic renal failure
  • 125/75 for those with chronic renal failure of any aetiology if they also have proteinuria >1g/d (Prot/Creat ratio > 100mglmmol), unless this lower target is contraindicated

ACE inhibitors are proven to be particularly effective at protecting renal function in patients with proteinuria. A2R antagonists are likely to be equally effective. Non-dihydropyridine calcium antagonists (verapamil, diltiazem) have some theoretical (not proven) advantage if patients cannot tolerate ACEI or A2R blockade.

Blood pressure targets should be individualised, as patients have different circumstances. For example, patients of black race should possibly have lower targets as the risk of end organ damage is greater. Very young patients may merit lower targets.

It is sometimes useful to consider average blood pressure at different ages – although it must be noted that there is no evidence to support using these as therapeutic targets.

Age

18-24

25-34

35-44

45-54

55-64

65-74

Systolic

125

128

128

134

141

145

Diastolic

62

69

74

79

80

78

Systolic

117

117

121

130

139

149

Diastolic

62

66

70

73

74

73

Blood pressure and proteinuria

Lowering blood pressure can reduce proteinuria. ACE inhibitors and ARBs achieve greater lowering of proteinuria than other first-line hypotensive agents.

Other proteinuria-reducing strategies are mentioned on the proteinuria page.

Patient information

High blood pressure and kidney disease from EdRenINFO

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