Division of Nephrology, University of Ottawa, Ottawa, Ontario.
Department of Medicine, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, University of Calgary, Calgary, Alberta.
Am J Kidney Dis. 2014 Jun;63(6):869-87. doi: 10.1053/j.ajkd.2014.03.003. Epub 2014 Apr 12.
The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) provides the structural and evidence base for the Canadian Society of Nephrology (CSN) commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 13 of the 21 KDIGO guideline statements. Specifically, we agreed that nonpharmacological interventions should play a significant role in the management of hypertension in patients with CKD. We also agreed that the approach to the management of hypertension in elderly patients with CKD should be individualized and take into account comorbid conditions to avoid adverse outcomes from excessive BP lowering. In contrast to KDIGO, the CSN Work Group believes there is insufficient evidence to target a lower BP for nondiabetic CKD patients based on the presence and severity of albuminuria. The CSN Work Group concurs with the Canadian Hypertension Education Program (CHEP) recommendation of a target BP for all non-dialysis-dependent CKD patients without diabetes of ≤140 mm Hg systolic and ≤90 mm Hg diastolic. Similarly, it is our position that in diabetic patients with CKD and normal urinary albumin excretion, raising the threshold for treatment from <130 mm Hg systolic BP to <140 mm Hg systolic BP could increase stroke risk and the risk of worsening kidney disease. The CSN Work Group concurs with the CHEP and the Canadian Diabetic Association recommendation for diabetic patients with CKD with or without albuminuria to continue to be treated to a BP target similar to that of the overall diabetes population, aiming for BP levels < 130/80 mm Hg. Consistent with this, the CSN Work Group endorses a BP target of <130/80 mm Hg for diabetic patients with a kidney transplant. Finally, in the absence of evidence for a lower BP target, the CSN Work Group concurs with the CHEP recommendation to target BP<140/90 mm Hg for nondiabetic patients with a kidney transplant.
KDIGO（肾脏病：改善全球预后）2012 年慢性肾脏病（CKD）血压管理临床实践指南为加拿大肾脏病学会（CSN）对该指南与加拿大医疗保健系统相关性和适用性的评论提供了结构和证据基础。虽然我们总体上达成一致，但我们对 KDIGO 指南的 21 条声明中的 13 条发表了评论。具体来说，我们同意非药物干预措施应在 CKD 患者高血压管理中发挥重要作用。我们还同意，在患有 CKD 的老年患者中，高血压的管理方法应个体化，并考虑到合并症，以避免因过度降压而产生不良后果。与 KDIGO 不同的是，CSN 工作组认为，基于白蛋白尿的存在和严重程度，针对非糖尿病 CKD 患者的更低血压目标没有足够的证据。CSN 工作组同意加拿大高血压教育计划（CHEP）的建议，即所有无糖尿病的非透析依赖 CKD 患者的目标血压为收缩压≤140mmHg 和舒张压≤90mmHg。同样，我们的立场是，对于 CKD 且尿白蛋白正常排泄的糖尿病患者，将治疗阈值从<130mmHg 收缩压提高到<140mmHg 收缩压可能会增加中风风险和肾脏疾病恶化的风险。CSN 工作组同意 CHEP 和加拿大糖尿病协会的建议，即对于有或没有白蛋白尿的 CKD 糖尿病患者，继续以类似于总体糖尿病人群的血压目标进行治疗，目标血压为<130/80mmHg。与此一致，CSN 工作组支持对于接受肾移植的糖尿病患者，将血压目标设定为<130/80mmHg。最后，在缺乏更低血压目标的证据的情况下，CSN 工作组同意 CHEP 的建议，对于无糖尿病的肾移植患者，将血压目标设定为<140/90mmHg。
