Blood Pressure Targets in CKD 2021: The Never-ending Guidelines Debacle Ⅱ

FUTURE DIRECTIONS

In conclusion, it is highly disappointing that two reference guideline bodies drastically disagree, without a detailed rationale, on guidance on such basic and universal items as BP targets for the 850 million people with CKD (Box 1) [16–18]. Strong bidirectional and/or multidirectional communication channels should be established between guideline bodies to prevent the future occurrence of such blatant discrepancies. The individualism that has presided over guidelines generation should become a thing of the past. In a worst-case scenario, guideline bodies should agree to disagree in a common document in which each guideline body explains the rationale for their choice of BP targets that may result from assigning different weights to different aspects of the evidence or impact that may range from emphasizing safety or efficacy, cost or implementation aspects, among others. These considerations should be clearly stated in the common document, helping national scientific societies, healthcare providers and payers, and individual physicians to draw their conclusions. Otherwise, we run the risk of compromising implementation, given the doubts raised by such different targets, and providing ammunition for guidelines and science skeptics. In a best-case scenario, consensus is reached on a single BP target. This may be facilitated by a body of experts in the field of hypertension in CKD representing and shared by different societies (Fig. 2).

HOW LONG DOES IT TAKE FOR CISTANCHE TO WORK?

Box 1. Key questions and answers regarding the discrepancy in SBPtargets between 2021 KDIGo and2021 ESC guidelines that provide guidance on BP targets for people with CKD

Do the new guidelines cite different evidence for their BP targets in people with CKD?

No. The 2021 EsC guideline does not cite any evidence to support its BP targets for people with However, the 2018 ESC/ESH guideline states that: 'evidence concerning BP targets in patients with CKDis complex" and cites a 2003 meta-analysis, a 2011 sys. systematic review and a 2014 retrospective study [16-18]While KDIGO 2021 cites evidence from SPRINT to support the new suggested SBp target, 2021 EsC acknowledges SPRlNT for recommendations for people who do not have CKD but does not mention SPRINT in the discussion of BP targets for CKD.

Do the new guidelines recommend different methods to measure office BP?

Not really. Standardized office BP measurement is the recommended method for evaluating BP in both(Table 1).

Does the most recent guideline (ESc 2021)acknowledge the guidelines published earlier in the same year (KDiGo) and discuss why they do not agree on the same BP targets?

No.

Does the European guideline offer some explanation as to why the BP targets recommended by European scientific societies should differ from those suggested for the global population of people with CKD by KDIGO?

No. In the 2021 ESC guidelines, there is no discussion on the evidence for BP targets in CKD.

FIGURE 2: Proposal to limit the disagreement between clinical practice guidelines on BP targets for people with CKD. A shared group of experts who have expertise in both hypertension and CKD may represent the different societies/guideline bodies. These experts would be identified and selected based on internal rules by each guideline body and may undergo turnover as per these rules. The rules of engagement of this committee of experts may be decided in the future, e.g. whether consensus would be needed between all experts for a specific guideline from a single guideline body, but at least the integrated discussion between experts representing different guideline bodies would contribute to reaching consensus between guidelines that limits the most egregious disagreements, or at least, to provide a rationale for choosing certain BP targets and not others.

AUTHORS

CONTRIBUTIONS 

All authors brainstormed for the concept of the manuscript. S.C. and A.O. generated the draft. All authors provided critical insights to the draft and approved the final version. 

CONFLICT OF INTEREST STATEMENT

A.O. has received consultancy or speaker fees or travel support from Advicciene, Astellas, AstraZeneca, Amicus, Amgen, Fregenius Medical Care, Bayer, Sanofi Genzyme, Menarini, Kyowa Kirin, Alexion, Idorsia, Chiesi, Otsuka, Novo Nordisk and Vifor Fresenius Medical Care Renal Pharma and is Director of the Catedra Mundipharma-UAM of diabetic kidney disease and the Catedra AstraZeneca-UAM of CKD and electrolytes. A.O. is the Editor-in-Chief of CKJ. P.S. has received consultancy or speaker fees or travel support from Elpen, Genesis Pharma, AstraZeneca, Menarini, Innovis Pharma, Winmedica, Bayer, Amgen, Boehringer Ingelheim, Winmedica and Genesis Pharma. S.C. has participated in an advisory board for Otsuka.

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