What Is Wrong with the Blood Pressure Target Recommendation of KDIGO 2021 for Hypertension in Chronic Kidney Disease?

Eighty-five percent of patients with chronic kidney disease (CKD) have hypertension, and blood pressure (BP) control is the cornerstone in the management of CKD. Although it is widely accepted that BP should be optimized, BP targets in CKD are not known. Subject of Review: Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline for the management of BP in CKD (Kidney Int. 2021 Mar 1;99(3S):S1-87) recommends targeting BP to less than 120 mm Hg systolic for patients with CKD. Second Opinion: KDIGO BP target differs from all other hypertension guidelines. This is also a major change from the previous recommendation which was <140 systolic to all patients with CKD and <130 systolic for those with proteinuria. Targeting systolic BP to less than 120 mm Hg is hard to substantiate based on available data and is based primarily on subgroup analysis of a randomized control trial. Intensive BP lowering as suggested by the guidelines may lead to polypharmacy, added cost burden, and risk of serious harms.