title: Canadian Society of Nephrology commentary on the 2012 KDIGO clinical practice guideline for the management of blood pressure in CKD.
abstract: The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) provides the structural and evidence base for the Canadian Society of Nephrology (CSN) commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 13 of the 21 KDIGO guideline statements. Specifically, we agreed that nonpharmacological interventions should play a significant role in the management of hypertension in patients with CKD. We also agreed that the approach to the management of hypertension in elderly patients with CKD should be individualized and take into account comorbid conditions to avoid adverse outcomes from excessive BP lowering. In contrast to KDIGO, the CSN Work Group believes there is insufficient evidence to target a lower BP for nondiabetic CKD patients based on the presence and severity of albuminuria. The CSN Work Group concurs with the Canadian Hypertension Education Program (CHEP) recommendation of a target BP for all non-dialysis-dependent CKD patients without diabetes of ≤140 mm Hg systolic and ≤90 mm Hg diastolic. Similarly, it is our position that in diabetic patients with CKD and normal urinary albumin excretion, raising the threshold for treatment from <130 mm Hg systolic BP to <140 mm Hg systolic BP could increase stroke risk and the risk of worsening kidney disease. The CSN Work Group concurs with the CHEP and the Canadian Diabetic Association recommendation for diabetic patients with CKD with or without albuminuria to continue to be treated to a BP target similar to that of the overall diabetes population, aiming for BP levels < 130/80 mm Hg. Consistent with this, the CSN Work Group endorses a BP target of <130/80 mm Hg for diabetic patients with a kidney transplant. Finally, in the absence of evidence for a lower BP target, the CSN Work Group concurs with the CHEP recommendation to target BP<140/90 mm Hg for nondiabetic patients with a kidney transplant.
authors.affiliation: Division of Nephrology, University of Ottawa, Ottawa, Ontario. Electronic address: mruzicka@ottawahospital.on.ca.
authors.forename: Marcel
authors.initials: M
authors.lastname: Ruzicka
authors.affiliation: Department of Medicine, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, University of Calgary, Calgary, Alberta.
authors.forename: Robert R
authors.initials: RR
authors.lastname: Quinn
authors.affiliation: Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario.
authors.forename: Phil
authors.initials: P
authors.lastname: McFarlane
authors.affiliation: Department of Medicine, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, University of Calgary, Calgary, Alberta.
authors.forename: Brenda
authors.initials: B
authors.lastname: Hemmelgarn
authors.affiliation: Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario.
authors.forename: G V
authors.initials: GV
authors.lastname: Ramesh Prasad
authors.affiliation: Division of Nephrology, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa.
authors.forename: Janusz
authors.initials: J
authors.lastname: Feber
authors.affiliation: The Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario; Division of Nephrology, Humber River Regional Hospital, Toronto, Ontario.
authors.forename: Gihad
authors.initials: G
authors.lastname: Nesrallah
authors.affiliation: Division of Nephrology, Saint John Regional Hospital, Saint John, New Brunswick.
authors.forename: Martin
authors.initials: M
authors.lastname: MacKinnon
authors.affiliation: Division of Nephrology, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba.
authors.forename: Navdeep
authors.initials: N
authors.lastname: Tangri
authors.affiliation: Division of Nephrology, University of Ottawa, Ottawa, Ontario.
authors.forename: Brendan
authors.initials: B
authors.lastname: McCormick
authors.affiliation: Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario.
authors.forename: Sheldon
authors.initials: S
authors.lastname: Tobe
authors.affiliation: Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba.
authors.forename: Tom D
authors.initials: TD
authors.lastname: Blydt-Hansen
authors.affiliation: Division of Nephrology, University of Ottawa, Ottawa, Ontario.
authors.forename: Swapnil
authors.initials: S
authors.lastname: Hiremath
mesh_terms: D002170:Canada; D003928:Diabetic Nephropathies / Q000503:physiopathology; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000628:therapy*; D008019:Life Style; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000503:physiopathology*; D012955:Societies, Medical; D012982:Sodium, Dietary / Q000008:administration & dosage
chemical_list: D012982:Sodium, Dietary
keywords: Canadian Society of Nephrology (CSN); Hypertension; Kidney Disease: Improving Global Outcomes (KDIGO); chronic kidney disease (CKD); clinical practice guideline; commentary