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Targets (how low should it be?) | IndividualizingChildrenwith proteinuria | kidney damage | patient info

Blood pressure targets

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.


In individual patients

Targets should be individualised, as patients have different circumstances.  Benefits from blood pressure reduction do not seem to have age limits, but younger patients might be treated more aggressively as their lifetime risk of end organ damage is greater.

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.  Figures are from Scotland, 1998.

 
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

 

Blood pressure in children

We have a separate page on blood pressure in children

 

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.

There is more on proteinuria-reducing strategies on the proteinuria page. 

 

Kidney damaged caused by high blood pressure

High blood pressure is a common sign of kidney disease but it is unusual for it to be the only cause.

Very severe, or 'malignant' hypertension, can damage the kidneys. This is also called 'accelerated' hypertension.

The evidence that moderate hypertension is an important primary cause of renal failure is weak, and we should not use it as a label when we really mean 'cause uncertain'.
 

Patient information

High blood pressure and kidney disease from EdRenINFO

 

Acknowledgements:   Neil Turner was the main author for this page. It received substantial revisions in August 2001, July 2002, November 2006, May 2010. The last amended date is shown in the footer. 

Licensed under a Creative Commons LicenseCreative Commons Attribution 4.0 International License.

K  

This page last modified 05.08.2013 08:45 by Emma Farrell. edren and edrep are produced by the Renal Unit at the Royal Infirmary of Edinburgh and the University of Edinburgh. CAUTIONS and Contact us.