Blood pressure in renal disease


Abbreviated medical protocols from EdREN, the website of the Renal Unit of the Royal Infirmary of Edinburgh


There is strong evidence that lower than usual targets are beneficial in renal diseases, but especially in those associated with significant proteinuria. Any limits set are arbitrary, but for example, the current SIGN and NICE guideline levels are:

  • Proteinuria low: ACR<70 or PCR<100 - Target blood pressure <140/90 (NICE suggests 130-139/90)
  • Proteinuria high: ACR>70 or PCR>100: - Target blood pressure <130/80 (NICE suggests 120-129/80)

ACE inhibitors or ARBs should be included in:

  • Patients with urinary ACR>30 or PCR>50
  • Diabetics with microalbuminuria, even in the absence of hypertension


The previous UK CKD guidelines and some US guidance recommended slightly lower targets, and some nephrologists favour these:

  • 130/80 for patients with diabetes mellitus and microalbuminuria (but note that diabetics with microalbuminuria benefit from ACE inhibitors at all levels of blood pressure, including normal levels)
  • 130/80 for non-diabetic patients with chronic renal failure
  • 125/75 for those with chronic renal failure of any aetiology if they also have proteinuria >1g/d (Prot/Creat ratio > 100mglmmol), unless this lower target is contraindicated

ACE inhibitors are proven to be particularly effective at protecting renal function in patients with proteinuria. A2R antagonists are likely to be equally effective. Non-dihydropyridine calcium antagonists (verapamil, diltiazem) have some theoretical (not proven) advantage if patients cannot tolerate ACEI or A2R blockade.

Blood pressure targets should be individualised, as patients have different circumstances. For example, patients of black race should possibly have lower targets as the risk of end organ damage is greater. Very young patients may merit lower targets.

It is sometimes useful to consider average blood pressure at different ages - although it must be noted that there is no evidence to support using these as therapeutic targets.


 

Age

18-24

25-34

35-44

45-54

55-64

65-74
MALE
Systolic

125

128

128

134

141

145
 
Diastolic

62

69

74

79

80

78
FEMALE
Systolic

117

117

121

130

139

149
 
Diastolic

62

66

70

73

74

73

Figures are for Scotland, 1998


Blood pressure and proteinuria

Lowering blood pressure can reduce proteinuria. ACE inhibitors and ARBs achieve greater lowering of proteinuria than other first-line hypotensive agents.

Other proteinuria-reducing strategies are mentioned on the proteinuria page.

Patient information

High blood pressure and kidney disease from EdRenINFO

 

Neil Turner was the main author for this page. It was revised in August 2001, July 2002, November 2006, last amended Thursday, February 5, 2009.

NOTE that the accuracy of any statements in this information CANNOT be guaranteed. It is published in the belief that it is correct, and we endeavour to keep it so - but we do make mistakes. Furthermore, over some subjects there are differing opinions, or differing degrees of certainty. We have usually not attempted to discuss these here because the aim has been to provide an immediate and brief guide. In all areas, prior medical knowledge is assumed. The EdRenHANDBOOK is not suitable for use by those without such a background. Contact us by email or at the address given at the foot of the contents page with any comments or corrections.

 


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