Blood Pressure Guideline
Guiding Principles
Hypertension can be a cause and complication of Advanced Chronic Kidney Disease (ACKD). Blood pressure should be monitored on a regular basis, including an assessment for orthostatic hypotension.
We suggest that adults with high BP and CKD be treated with a target systolic blood pressure of <120 mm Hg, when tolerated, using standardized office BP measurement (2B).
Medications: Angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB) should be first-line therapy for hypertension when albuminuria is present, otherwise dihydropyridine calcium channel blocker (CCB) or diuretic can also be considered; all 3 classes are often needed to attain blood pressure targets.
Lifestyle considerations. Encourage people to undertake physical activity compatible with cardiovascular health, tolerance, and level of frailty; achieve an optimal body mass index; and not use tobacco products.
Consider less intensive BP-lowering therapy in people with frailty, high risk of falls, very limited life expectancy, or symptomatic postural hypotension.
For patients receiving conservative kidney management, the primary goal of blood pressure management is to optimize function and quality of life and minimizing the risk of falls while avoiding very high readings. Individualization is key.
GFR 15 - 5 | Slow Decline/Deteriorating | Last 0-5 years of life
In line with guidelines for the care of frail older persons, it may be reasonable to relax the suggested blood pressure targets for CKM patients with a GFR ≤ 15 to ≤150/90. This applies to patients with diabetes as well.
Decisions about specific medications will depend on the patient and their co-morbidities. Prescribers should attempt to use medications that work for more than one condition and should consider that the patient might have strong feelings about continuing or stopping certain medications.
Diuretics will likely be one of the last medications stopped.
GFR 5 - 0 | Intensive/Near Death | Last 0-2 months of life
When a patient becomes bed-bound, it is usually no longer necessary to monitor blood pressure. Blood pressure medications can be stopped at this point.
Diuretics are a unique consideration and can play an important role in the relief of dyspnea associated with volume overload. If a patient continues to eat and drink, it is acceptable to continue with diuretics. In most cases, once a person is no longer eating or drinking, diuretics should be stopped (e.g. when urine output is < 250 cc/day on the maximum furosemide (Lasix) dose of 120 mg BID, furosemide (Lasix) should be stopped).