Cardiovascular Implications of the 2021 KDIGO Blood Pressure Guideline for Adults With Chronic Kidney Disease

The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends a systolic blood pressure (BP) target of <120 mm Hg for nondialysis chronic kidney disease (CKD).We sought to examine the potential implications of the 2021 KDIGO BP target, compared with the 2012 KDIGO and 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP targets, as related to cardiovascular disease (CVD) outcomes.From the cross-sectional Korea National Health and Nutrition Examination Survey (KNHANES) and longitudinal National Health Insurance Service (NHIS) data, adults with nondialysis CKD were identified and categorized into 4 groups based on concordance/discordance between guidelines: 1) above both targets; 2) above 2021 KDIGO only; 3) above 2012 KDIGO or 2017 ACC/AHA only; and 4) controlled within both targets. We determined the nationally representative proportion and CVD risk of each group.In KNHANES (n = 1,939), 50.2% had BP above both 2021 and 2012 KDIGO targets, 15.9% above the 2021 KDIGO target only, 3.5% above the 2012 KDIGO target only, and 30.4% controlled within both targets. In NHIS (n = 412,167; median follow-up: 10.0 years), multivariable-adjusted HRs for CVD events were 1.52 (95% CI: 1.47-1.58) among participants with BP above both targets, 1.28 (95% CI: 1.24-1.32) among those with BP above 2021 KDIGO only, and 1.07 (95% CI: 0.61-1.89) among those with BP above 2012 KDIGO only, compared to those with BP controlled within both targets. Results were similar for comparison between 2021 KDIGO and 2017 ACC/AHA BP targets.New candidates for BP-lowering treatment per the 2021 KDIGO guideline account for a substantial proportion of the total CKD population and bear significantly high CVD risk.