Updated Blood Pressure Guidelines from Major Bodies Agree on Targets in Kidney Disease

Two major sets of hypertension guidelines released in 2014 contain more common threads than differences, and are intended to serve different purposes. Clinicians seeking guidance for managing hypertension in chronic kidney disease (CKD) can look for this common ground to avoid “guideline overload,” said the Mayo Clinic’s Sandra Taler, MD, Professor of Medicine in the Divisions of Nephrology and Hypertension.

Speaking to a full room during a hypertension update session at Kidney Week on November 15, 2014 in Philadelphia, Taler began by reviewing the aims of the 2014 Evidence-Based Guideline from the Eighth Joint National Committee (JNC 8). The committee, which included Taler, used a stratification system to rely on the highest available evidence to make recommendations, and then also graded the strength of its recommendations. This transparent process will help clinicians give appropriate weight to the guidelines in clinical decisionmaking, she said.

JNC 8’s algorithm begins with recommendations to implement lifestyle interventions for all individuals with elevated blood pressure (BP). The decision tree then bifurcates, and special consideration is given to those with diabetes and/or CKD. The presence of either of these conditions for individuals of any age triggers a systolic/diastolic blood pressure goal of less than 140/90 mm Hg. Continuing the emphasis on evidence-supported recommendations, at no point does the JNC 8 Guideline recommend a target below 140/90 for any population.

If kidney disease is present, initial pharmacotherapy should be an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB). For those with diabetes but no kidney disease and not of African-American ancestry, first-line therapy should be a thiazide diuretic, an ACEI or ARB, or a calcium-channel blocker (CCB), alone or in combination. African-Americans should begin with a thiazide or a CCB alone or in combination.

In the absence of strong evidence supporting one titration strategy over another, JNC 8 guidelines give clinical leeway for maximizing monotherapy, initiating two medications, or adding a second medication to achieve BP control. For all individuals, the guidelines recommend reserving beta blockade for second-line therapy in the absence of a compelling medical rationale for first-line use. Medication adherence and lifestyle modification should be reinforced at each stage of treatment.

Next, Taler reviewed the American Society of Hypertension-International Society of Hypertension (ASH-ISH) Clinical practice Guidelines for the Management of Hypertension in the Community. This lengthy document, Taler explained, was really intended to be a hypertension curriculum with a focus on primary care providers around the globe. The philosophy, she explained, is that “simple empiric care is better than no care.”

The 2014 ASH-ISH treatment algorithm also recommends beginning treatment when BP is greater than 140/90 mm Hg in all adults with kidney disease or diabetes, again recommending lifestyle interventions along with medication. Drug therapy for those with CKD and/or diabetes is immediately broken out into a set of “special cases,” recommending initial treatment with an ACEI or ARB for both conditions.

A CCB or thiazide may be used as first-line treatment for black patients with diabetes, but an ARB or ACEI should be considered as a second drug if needed. Second-line treatment for those with hypertension and CKD can be a CCB or thiazide diuretic in the ASH-ISH guidelines.

Both guidelines, said Taler, can be used by clinicians, though they still will need to consider patient-specific factors to tailor treatment. In response to questioning, she called for future trials to address gaps in the evidence for lower target blood pressures, and in fine-tuning hypertensive regimes.