KDIGO Clinical Practice Guideline for the Management of ...

1 Volume 2 | issue 5 | DeCemBeR 2012 JOurnal Of the internatiOnal SOciety Of nephrOlOgyKDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney DiseaseKDIGO Clinical Practice Guidelinefor the Management of Blood Pressure inChronic Kidney DiseaseKDIGO 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 FoodCompany, Fresenius Medical Care, Genzyme, Hoffmann-LaRoche, JC Penney, Kyowa Hakko Kirin, NATCO TheOrganization 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 Statement.

2 KDIGO is supported by a consortium of sponsors and no funding is accepted for the developmentof specific Clinical Practice Guideline for the Management of Blood Pressurein Chronic Kidney DiseaseTablesvKDIGO Board MembersviReference KeysviiAbbreviations and AcronymsviiiNotice337 Foreword338 Work Group Membership339 Abstract340 Summary of Recommendation Statements341 Chapter 1: Introduction343 Chapter 2: Lifestyle and pharmacological treatments for lowering blood pressure in CKD ND patients347 Chapter 3: Blood pressure Management in CKD ND patients without diabetes mellitus357 Chapter 4: Blood pressure Management in CKD ND patients with diabetes mellitus363 Chapter 5: Blood pressure Management in kidney transplant recipients (CKD T)370 Chapter 6: Blood pressure Management in children with CKD ND372 Chapter 7: Blood pressure Management in elderly persons with CKD ND377 Chapter 8.

3 Future directions and controversies382 Methods for Guideline Development388 Biographic and Disclosure Information398 Acknowledgments404 References405 KDIGOVOL 2 | ISSUE 5 | DECEMBER 2012 TABLEST able 1. Relationship among categories for albuminuria and proteinuria345 Table 2. Selected calcium-channel blockers355 Table 3. Questions for future research381 Table 4. Existing guidelines on ambulatory BP monitoring (ABPM) and home BP monitoring383 Table 5. Systematic review topics and screening criteria389 Table 6. Hierarchy of outcomes389 Table 7. Relevant systematic reviews and meta-analyses390 Table 8.

4 Literature yield390 Table 9. Work products for BP guideline391 Table 10. Classification of study quality392 Table 11. GRADE system for grading quality of evidence392 Table 12. Final grade for overall quality of evidence393 Table 13. Balance of benefits and harms393 Table 14. KDIGO nomenclature and description for grading recommendations393 Table 15. Determinants of strength of recommendation393 Table 16. Existing major guidelines and recommendations on hypertension and anti-hypertensive agents in CKD394 Table 17. The Conference on Guideline Standardization (COGS) checklist for reporting Clinical Practice guidelines396 Additional information in the form ofsupplementary materials can be found online at KDIGOK idney International Supplements(2012)

5 2,vvKDIGO Board MembersGarabed Eknoyan, MDNorbert Lameire, MD, PhDFounding KDIGO Co-ChairsKai-Uwe Eckardt, MDImmediate Past Co-ChairBertram L Kasiske, MDKDIGO Co-ChairDavid C Wheeler, MD, FRCPKDIGO Co-ChairOmar I Abboud, MD, FRCPS haron Adler, MD, FASNR ajiv Agarwal, MDSharon P Andreoli, MDGavin J Becker, MD, FRACPFred Brown, MBA, FACHED aniel C Cattran, MD, FRCPCA llan J Collins, MD, FACPR osanna Coppo, MDJosef Coresh, MD, PhDRicardo Correa-Rotter, MDAdrian Covic, MD, PhDJonathan C Craig, MBChB, MM (Clin Epi), DCH, FRACP, PhDAngel de Francisco, MDPaul de Jong, MD, PhDAna Figueiredo, RN, MSc, PhDMohammed Benghanem Gharbi, MDGordon Guyatt, MD, MSc, BSc, FRCPCD avid Harris, MDLai Seong Hooi, MDEnyu Imai, MD, PhDLesley A Inker, MD, MS, FRCPM ichel Jadoul, MDSimon Jenkins, MBE, FRCGPS uhnggwon Kim, MD, PhDMartin K Kuhlmann, MDNathan W Levin, MD, FACPP hilip K-T Li, MD, FRCP, FACPZhi-Hong Liu, MDPablo Massari, MDPeter A McCullough, MD, MPH, FACC, FACPR afique Moosa, MDMiguel C Riella, MDAdibul Hasan Rizvi, MBBS, FRCPB ernardo Rodriquez-Iturbe, MDRobert Schrier, MDJustin Silver, MD.

6 PhDMarcello Tonelli, MD, SM, FRCPCY usuke Tsukamoto, MDTheodor Vogels, MSWA ngela Yee-Moon Wang, MD, PhD, FRCPC hristoph Wanner, MDElena Zakharova, MD, PhDNKF- KDIGO Guideline DEVELOPMENT STAFFK erry Willis, PhD, Senior Vice-President for Scientific ActivitiesMichael Cheung, MA, Guideline Development DirectorSean Slifer, BA, Guideline Development ManagerKidney International Supplements(2012)2, KDIGOCONVERSION FACTORS OF METRIC UNITS TO SI UNITSP arameterMetric unitsConversion factorSI unitsBlood urea (serum) : Metric unit conversion factor SI of evidenceMeaningAHighWe are confident that the true effect lies close to that of the estimate of the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially true effect may be substantially different from the estimate of the lowThe estimate of effect is very uncertain, and often will be far from the CHRONIC KIDNEY DISEASE (CKD) NOMENCLATURE USED BY KDIGOCKD categoriesDefinitionCKDCKD of any stage (1 5)

7 , with or without a kidney transplant, including both non-dialysisdependent CKD (CKD 1 5 ND) and dialysis-dependent CKD (CKD 5D)CKD NDNon-dialysis-dependent CKD of any stage (1 5), with or without a kidney transplant( , CKD excluding CKD 5D)CKD TNon-dialysis-dependent CKD of any stage (1 5) with a kidney transplantSpecific CKD StagesCKD 1, 2, 3, 4 Specific stages of CKD, CKD ND, or CKD TCKD 3-4, of specific stages ( , both CKD 3 and CKD 4)CKD 5 DDialysis-dependent CKD 5 CKD 5 HDHemodialysis-dependent CKD 5 CKD 5 PDPeritoneal dialysis-dependent CKD 5 ImplicationsGrade*PatientsCliniciansPoli cyLevel 1 We recommend Most people in your situation would wantthe recommended course of action and onlya small proportion would patients should receive therecommended course of recommendation can be evaluated as acandidate for developing a policy or aperformance 2 We suggest The majority of people in your situationwould want the recommended course ofaction.

8 But many would choices will be appropriate fordifferent patients. Each patient needs help toarrive at a Management decision consistentwith her or his values and recommendation is likely to requiresubstantial debate and involvement ofstakeholders before policy can bedetermined.*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 most common examples include recommendations regarding monitoring intervals, counseling, and referral to other Clinical specialists. The ungraded recommendationsare generally written as simple declarative statements, but are not meant to be interpreted as being stronger recommendations than Level 1 or 2 AND DESCRIPTION FOR RATING Guideline RECOMMENDATIONSW ithin each recommendation, the strength of recommendation is indicated asLevel 1,Level 2,orNot Graded, and the quality of thesupporting evidence is shown asA,B,C, KeysCKD StageDescriptionGFR (ml/min per m2)

9 1 Kidney damage with normal or increased GFRZ902 Kidney damage with mild decreased GFR60 893 Moderate decreased GFR30 594 Severe decreased GFR15 295aKidney failureo15 (or dialysis)CKD, chronic kidney disease; GFR, glomerular filtration 1 5T notation applies to kidney transplant if dialysis (HD or PD).STAGES OF CHRONIC KIDNEY DISEASEK idney International Supplements(2012)2, KDIGOK idney International Supplements(2012)2, viiiviiiAbbreviations and AcronymsAASKA frican American Study of Kidney Disease andHypertensionABCDA ppropriate Blood Pressure Control in DiabetesABPMA mbulatory blood pressure monitoringACCFA merican College of Cardiology FoundationACCORDA ction to Control Cardiovascular Risk in DiabetesACE-IAngiotensin-converting enzyme inhibitorACRA lbumin/creatinine ratioADVANCEA ction in Diabetes and Vascular Disease.

10 Preteraxand Diamicron Modified Release ControlledEvaluationAERA lbumin excretion rateAGREEA ppraisal of guidelines for Research and EvaluationAHAA merican Heart AssociationALLHATA ntihypertensive and Lipid-Lowering Treatmentto Prevent Heart Attack TrialALTITUDEA liskiren Trial in Type 2 Diabetes Using Cardio-vascular and Renal Disease EndpointsARBA ngiotensin-receptor blockerBMIBody mass indexBPBlood pressureCADC oronary artery diseaseCASE JCandesartan Antihypertensive SurvivalEvaluation in JapanCIConfidence intervalCKDC hronic kidney diseaseCKD-EPICKD Epidemiology