Summary

Update to the 2012 KDIGO BP guideline covering BP measurement, lifestyle interventions, antihypertensive therapy in CKD (with/without diabetes), kidney transplant recipients, and children. Major changes from 2012: emphasis on standardized office BP measurement, lower SBP target of <120 mm Hg for most adults with non-dialysis CKD (largely from SPRINT), and a unified target irrespective of diabetes, proteinuria, or older age. Renin-angiotensin system inhibitors remain first-line for CKD with albuminuria; dual RAS blockade is to be avoided.

Key Recommendations

Use standardized office BP measurement (proper preparation, validated device, averaged readings) rather than routine office BP for managing high BP in adults (1B).
Complement standardized office BP with out-of-office measurements (ABPM or HBPM) to identify white-coat and masked hypertension (2B).
Target SBP <120 mm Hg using standardized office BP measurement in adults with high BP and CKD not on dialysis, when tolerated (2B).
Restrict dietary sodium to <2 g/day (<90 mmol/day, <5 g NaCl/day) in patients with high BP and CKD (2C); avoid in salt-wasting nephropathy.
Advise moderate-intensity physical activity ≥150 minutes per week, individualized to cardiovascular and physical tolerance (2C).
Start ACEi or ARB in patients with high BP, CKD G1–G4, and severely increased albuminuria (A3) without diabetes (1B).
Start ACEi or ARB in patients with high BP, CKD G1–G4, and moderately increased albuminuria (A2) without diabetes (2C).
Start ACEi or ARB in patients with high BP, CKD G1–G4, and moderately-to-severely increased albuminuria (A2 or A3) with diabetes (1B).
Use the highest approved tolerated dose of RASi; check BP, serum creatinine, and potassium within 2–4 weeks of initiation or dose increase; continue RASi unless creatinine rises >30% within 4 weeks.
Avoid combination therapy with ACEi + ARB + direct renin inhibitor in any combination in CKD with or without diabetes (1B).
In adult kidney transplant recipients, target BP <130/80 mm Hg and use a dihydropyridine CCB or ARB as first-line antihypertensive (1C).
In children with CKD, target 24-hour MAP by ABPM ≤50th percentile for age, sex, and height (2C); use ACEi or ARB as first-line therapy.

Thresholds & Doses

Adult CKD non-dialysis SBP target: <120 mm Hg (standardized office measurement).
Kidney transplant recipient BP target: <130/80 mm Hg.
Pediatric CKD target: 24-hour MAP ≤50th percentile for age/sex/height by ABPM; if ABPM unavailable, office SBP <90th percentile.
Dietary sodium target: <2 g/day (<90 mmol/day; <5 g NaCl/day).
Physical activity target: ≥150 minutes per week of moderate-intensity activity.
Albuminuria categories: A1 <30 mg/g, A2 30–300 mg/g, A3 >300 mg/g (ACR).
Monitor BP, serum creatinine, potassium within 2–4 weeks after initiating or up-titrating RASi.
Continue RASi unless serum creatinine rises >30% within 4 weeks of initiation/dose increase.
Standardized BP measurement: ≥5 minutes seated rest; avoid caffeine/exercise/smoking for ≥30 minutes prior; cuff bladder encircles 80% of arm; average ≥2 readings on ≥2 occasions.
Consider dose reduction/discontinuation of ACEi/ARB for symptomatic hypotension, refractory hyperkalemia, or uremic symptoms with eGFR <15 ml/min/1.73 m².
MRA use caution if eGFR <45 ml/min/1.73 m² due to hyperkalemia risk.
RASi recommendations apply to CKD G1–G4 (no RCT data for CKD G5).

Citations

Chapter 1, Recommendation 1.1 and Figure 2 — standardized office BP measurement checklist.
Chapter 1, Recommendation 1.2 — ABPM/HBPM to complement office BP.
Chapter 2, Recommendation 2.1.1 — sodium intake <2 g/day target.
Chapter 2, Recommendation 2.2.1 — ≥150 min/week moderate-intensity physical activity.
Chapter 3, Recommendation 3.1.1 — SBP <120 mm Hg target (based on SPRINT).
Chapter 3, Recommendations 3.2.1–3.2.3 — RASi for CKD with albuminuria, with and without diabetes.
Chapter 3, Recommendation 3.3.1 — avoid dual RAS blockade (ONTARGET, VA-NEPHRON-D, ALTITUDE).
Chapter 4, Practice Point 4.1 and Recommendation 4.1 — transplant BP target <130/80 and CCB or ARB first-line.
Chapter 5, Recommendation 5.1 — pediatric 24-h MAP ≤50th percentile by ABPM (ESCAPE trial).