Real-World Adoption of the 2021 KDIGO BP Guideline in CKD

KEY POINTS: The proportion of patients with CKD whose systolic BP was within the 2021 Kidney Disease: Improving Global Outcomes (KDIGO) target increased by only 3.6% after the guideline's publication, remaining at 21.9% in 2024. The mean number of antihypertensive classes among patients with CKD increased minimally, by 0.02 (from 1.53 to 1.55), over the same period. Safety end points were generally comparable between patients with systolic BP above versus within the 2021 KDIGO target. BACKGROUND: The real-world uptake of the 2021 Kidney Disease: Improving Global Outcomes (KDIGO) BP guideline, which lowered the systolic BP target to <120 mm Hg for patients with CKD, is poorly understood. We examined the adoption of the 2021 KDIGO systolic BP target in clinical practice and its association with outcomes. METHODS: The study was based on data from the Mass General Brigham health care network, an integrated health care system spanning primary to tertiary care in New England. In the serial cross-sectional analysis, we identified approximately 50,000 patients with CKD stages 3-4 in each year from 2020 to 2024 and assessed the annual proportion of patients within the 2021 KDIGO systolic BP target. In longitudinal analysis, we identified 18,996 patients with incident CKD stages 3-4 in 2014-2019 and evaluated the association between systolic BP above versus within the target and clinical outcomes. RESULTS: In the serial cross-sectional analysis, 18.3% of patients with CKD had systolic BP within the 2021 KDIGO target in 2020 (preguideline). The proportion changed only marginally after the guideline's publication: 18.0% in 2021 (absolute difference, -0.3% [95% confidence interval (CI), -1.2 to 1.3]), 19.3% in 2022 (absolute difference, 1.0% [95% CI, -0.1 to 2.0]), 20.0% in 2023 (absolute difference, 1.7% [95% CI, 0.2 to 3.1]), and 21.9% in 2024 (absolute difference, 3.6% [95% CI, 1.9 to 5.3]). In longitudinal analysis, patients with systolic BP above the 2021 KDIGO target exhibited higher risks of cardio-kidney end points, lower risk of hypotension, and no differences in other safety end points compared to those within the target. CONCLUSIONS: Adoption of the 2021 KDIGO BP guideline remained limited in real-world practice. As of 2024, nearly four in five patients with CKD had systolic BP above the new guideline target.