KDIGO Clinical Practice Guideline for the …

1 Official Journal of the International Society of Nephrology KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease volume 2 | issue 5 | DECEMBER 2012. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease KDIGO gratefully acknowledges the following consortium of sponsors that make our initiatives possible: Abbott, Amgen, Bayer Schering Pharma, Belo Foundation, Bristol-Myers Squibb, Chugai Pharmaceutical, Coca-Cola Company, Dole Food Company, Fresenius Medical Care, Genzyme, Hoffmann-LaRoche, JC Penney, Kyowa Hakko Kirin, NATCO The Organization for Transplant Professionals, NKF-Board of Directors, Novartis, Pharmacosmos, PUMC Pharmaceutical, Robert and Jane Cizik Foundation, Shire, Takeda Pharmaceutical, Transwestern Commercial Services, Vifor Pharma, and Wyeth.

2 Sponsorship Statement: KDIGO is supported by a consortium of sponsors and no funding is accepted for the development of specific guidelines. contents & 2012 KDIGO . VOL 2 | ISSUE 5 | DECEMBER 2012. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease v Tables vi KDIGO Board Members vii Reference Keys viii Abbreviations and Acronyms 337 Notice 338 Foreword 339 Work Group Membership 340 Abstract 341 Summary of Recommendation Statements 343 Chapter 1: Introduction 347 Chapter 2: Lifestyle and pharmacological treatments for lowering blood pressure in CKD ND patients 357 Chapter 3: Blood pressure management in CKD ND patients without diabetes mellitus 363 Chapter 4: Blood pressure management in CKD ND patients with diabetes mellitus 370 Chapter 5: Blood pressure management in kidney transplant recipients (CKD T).

3 372 Chapter 6: Blood pressure management in children with CKD ND. 377 Chapter 7: Blood pressure management in elderly persons with CKD ND. 382 Chapter 8: Future directions and controversies 388 Methods for Guideline Development 398 Biographic and Disclosure Information 404 Acknowledgments 405 References contents & 2012 KDIGO . TABLES. 345 Table 1. Relationship among categories for albuminuria and proteinuria 355 Table 2. Selected calcium-channel blockers 381 Table 3. Questions for future research 383 Table 4. Existing guidelines on ambulatory BP monitoring (ABPM) and home BP monitoring 389 Table 5. Systematic review topics and screening criteria 389 Table 6. Hierarchy of outcomes 390 Table 7. Relevant systematic reviews and meta-analyses 390 Table 8. Literature yield 391 Table 9.

4 Work products for BP Guideline 392 Table 10. Classification of study quality 392 Table 11. GRADE system for grading quality of evidence 393 Table 12. Final grade for overall quality of evidence 393 Table 13. Balance of benefits and harms 393 Table 14. KDIGO nomenclature and description for grading recommendations 393 Table 15. Determinants of strength of recommendation 394 Table 16. Existing major guidelines and recommendations on hypertension and anti-hypertensive agents in CKD. 396 Table 17. The Conference on Guideline Standardization (COGS) checklist for reporting Clinical Practice guidelines Additional information in the form of supplementary materials can be found online at Kidney International Supplements (2012) 2, v v & 2012 KDIGO . KDIGO Board Members Garabed Eknoyan, MD.

5 Norbert Lameire, MD, PhD. Founding KDIGO Co-Chairs Kai-Uwe Eckardt, MD. Immediate Past Co-Chair Bertram L Kasiske, MD David C Wheeler, MD, FRCP. KDIGO Co-Chair KDIGO Co-Chair Omar I Abboud, MD, FRCP Michel Jadoul, MD. Sharon Adler, MD, FASN Simon Jenkins, MBE, FRCGP. Rajiv Agarwal, MD Suhnggwon Kim, MD, PhD. Sharon P Andreoli, MD Martin K Kuhlmann, MD. Gavin J Becker, MD, FRACP Nathan W Levin, MD, FACP. Fred Brown, MBA, FACHE Philip K-T Li, MD, FRCP, FACP. Daniel C Cattran, MD, FRCPC Zhi-Hong Liu, MD. Allan J Collins, MD, FACP Pablo Massari, MD. Rosanna Coppo, MD Peter A McCullough, MD, MPH, FACC, FACP. Josef Coresh, MD, PhD Rafique Moosa, MD. Ricardo Correa-Rotter, MD Miguel C Riella, MD. Adrian Covic, MD, PhD Adibul Hasan Rizvi, MBBS, FRCP. Jonathan C Craig, MBChB, MM (Clin Epi), DCH, FRACP, PhD Bernardo Rodriquez-Iturbe, MD.

6 Angel de Francisco, MD Robert Schrier, MD. Paul de Jong, MD, PhD Justin Silver, MD, PhD. Ana Figueiredo, RN, MSc, PhD Marcello Tonelli, MD, SM, FRCPC. Mohammed Benghanem Gharbi, MD Yusuke Tsukamoto, MD. Gordon Guyatt, MD, MSc, BSc, FRCPC Theodor Vogels, MSW. David Harris, MD Angela Yee-Moon Wang, MD, PhD, FRCP. Lai Seong Hooi, MD Christoph Wanner, MD. Enyu Imai, MD, PhD Elena Zakharova, MD, PhD. Lesley A Inker, MD, MS, FRCP. NKF- KDIGO Guideline DEVELOPMENT STAFF. Kerry Willis, PhD, Senior Vice-President for Scientific Activities Michael Cheung, MA, Guideline Development Director Sean Slifer, BA, Guideline Development Manager Kidney International Supplements (2012) 2, vi vi & 2012 KDIGO . Reference Keys NOMENCLATURE AND DESCRIPTION FOR RATING Guideline RECOMMENDATIONS.

7 Within each recommendation, the strength of recommendation is indicated as Level 1, Level 2, or Not Graded, and the quality of the supporting evidence is shown as A, B, C, or D. Implications Grade* Patients Clinicians Policy Level 1 Most people in your situation would want Most patients should receive the The recommendation can be evaluated as a We recommend' the recommended course of action and only recommended course of action. candidate for developing a policy or a a small proportion would not. performance measure. Level 2 The majority of people in your situation Different choices will be appropriate for The recommendation is likely to require We suggest' would want the recommended course of different patients. Each patient needs help to substantial debate and involvement of action, but many would not.

8 Arrive at a management decision consistent stakeholders before policy can be with her or his values and preferences. determined. *The additional category Not Graded' was used, typically, to provide guidance based on common sense or where the topic does not allow adequate application of evidence. The most common examples include recommendations regarding monitoring intervals, counseling, and referral to other Clinical specialists. The ungraded recommendations are generally written as simple declarative statements, but are not meant to be interpreted as being stronger recommendations than Level 1 or 2 recommendations. Grade Quality of evidence Meaning A High We are confident that the true effect lies close to that of the estimate of the effect. B Moderate The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

9 C Low The true effect may be substantially different from the estimate of the effect. D Very low The estimate of effect is very uncertain, and often will be far from the truth. STAGES OF CHRONIC KIDNEY DISEASE. CKD Stage Description GFR (ml/min per m2). 1 Kidney damage with normal or increased GFR Z90. 2 Kidney damage with mild decreased GFR 60 89. 3 Moderate decreased GFR 30 59. 4 Severe decreased GFR 15 29. 5a Kidney failure o15 (or dialysis). CKD, chronic kidney disease; GFR, glomerular filtration rate. CKD 1 5T notation applies to kidney transplant recipients. a 5D if dialysis (HD or PD). CURRENT CHRONIC KIDNEY DISEASE (CKD) NOMENCLATURE USED BY KDIGO . CKD categories Definition CKD CKD of any stage (1 5), with or without a kidney transplant, including both non-dialysis dependent CKD (CKD 1 5 ND) and dialysis-dependent CKD (CKD 5D).

10 CKD ND Non-dialysis-dependent CKD of any stage (1 5), with or without a kidney transplant ( , CKD excluding CKD 5D). CKD T Non-dialysis-dependent CKD of any stage (1 5) with a kidney transplant Specific CKD Stages CKD 1, 2, 3, 4 Specific stages of CKD, CKD ND, or CKD T. CKD 3-4, etc. Range of specific stages ( , both CKD 3 and CKD 4). CKD 5D Dialysis-dependent CKD 5. CKD 5HD Hemodialysis-dependent CKD 5. CKD 5PD Peritoneal dialysis-dependent CKD 5. CONVERSION FACTORS OF METRIC UNITS TO SI UNITS. Parameter Metric units Conversion factor SI units Blood urea nitrogen mg/ml mmol/l Creatinine (serum) mg/dl mmol/l Creatinine clearance ml/min ml/s Note: Metric unit conversion factor SI unit. Kidney International Supplements (2012) 2, vii vii & 2012 KDIGO . Abbreviations and Acronyms AASK African American Study of Kidney Disease and HOT Hypertension Optimal Treatment Hypertension HR Hazard ratio ABCD Appropriate Blood Pressure Control in Diabetes HYVET Hypertension in the Very Elderly Trial ABPM Ambulatory blood pressure monitoring ICD International Classification of Diseases ACCF American College of Cardiology Foundation IDNT Irbesartan Diabetic Nephropathy Trial ACCORD Action to Control Cardiovascular Risk in Diabetes INVEST International Verapamil SR Trandolapril study ACE-I Angiotensin-converting enzyme inhibitor JATOS Japanese Trial to Assess Optimal Systolic Blood ACR Albumin/creatinine ratio Pressure in Elderly Hypertensive Patients ADVANCE Action in Diabetes and Vascular Disease.