Key takeaways:

• The 2021 KDIGO BP guideline showed limited adoption over the 4 years following its publication.
• As of 2024, only one in five patients with CKD had systolic BP within the 2021 KDIGO BP target.

Only about one in five patients with chronic kidney disease met the 2021 Kidney Disease: Improving Global Outcomes systolic blood pressure target, according to study data published in the Journal of the American Society of Nephrology.

The 2021 KDIGO guideline on BP recommends a systolic BP target of less than 120 mm Hg for patients with CKD — a target lower than other BP guidelines at the time, according to Hyeok-Hee Lee, MD, PhD, a postdoctoral research fellow at Harvard Medical School.

Data derived from Lee HH, et al. J Am Soc Nephrol. 2026;doi:10.1681/ASN.0000001046.

“The SPRINT trial showed that targeting systolic BP under 120 mm Hg led to a lower risk of CVD than targeting systolic BP less than 140 mm Hg without any significant interaction by baseline CKD status” Lee told Healio. “Based on these findings, the 2021 KDIGO BP guidelines proposed a systolic BP target of less than 120 mm Hg, provided that BP is measured according to the standardized protocol as done in the SPRINT trial. This differs from the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP guidelines’ recommendation of a systolic BP target less than 130 mm Hg, which is also based on the findings from SPRINT, but also takes into account the typically non-standardized BP measurement methods used in routine clinical practice.”

“Given the paucity of CKD patient-oriented trials assessing the optimal BP target, and the discrepancy between the 2017 ACC/AHA and 2021 KDIGO BP guidelines, we naturally came to wonder to what extent the 2021 KDIGO BP target is adopted in real-world clinical practice,” So Mi Jemma Cho, PhD, postdoctoral fellow at Harvard Medical School, told Healio.

Using data from the Mass General Brigham healthcare network, the researchers, including Pradeep Natarajan, MD, MMSc, and colleagues, conducted two complementary analyses.

First, in a serial cross-sectional analysis, the researchers assessed the proportion of adults with CKD stage 3 or 4 who met the 2021 KDIGO systolic BP target each year from 2020 to 2024. About 50,000 adults were included in each year’s assessment: 51,404 adults (mean age, 73 years; 52% women) in 2020 and 45,651 adults (mean age, 75 years; 52% women) in 2024.

Results showed that the proportion of patients within the 2021 KDIGO systolic BP target changed marginally after the guideline’s publication, from 18.3% in 2020 (pre-guideline) to 21.9% in 2024 (absolute difference, 3.6 percentage points; 95% CI, 1.9-5.3).

In addition, the mean number of antihypertensive drugs used by patients increased by only 0.02 during the study period, from 1.53 to 1.55.

Then, in a longitudinal analysis, the researchers assessed clinical outcomes for 18,996 patients (mean age, 67 years; 55% women) with incident CKD stage 3 or 4 between 2014 and 2019.

The primary outcomes included kidney failure, CVD and five safety outcomes: hypotension, syncope, bradycardia, electrolyte abnormalities and injurious falls.

In this population, 19.8% of patients had systolic BP within the 2021 KDIGO target at index date.

During a median follow-up of 6.9 years, patients with systolic BP above the 2021 KDIGO target had greater risks for CVD (HR = 1.19; 95% CI, 1.11-1.27) and kidney failure (HR = 1.21; 95% CI, 1.08-1.35), lower risks for hypotension (HR = 0.8; 95% CI, 0.72-0.89) and no differences in other safety outcomes vs. patients within the 2021 KDIGO BP target.

The low adoption rate of the 2021 KDIGO BP guideline could stem from physicians’ concerns about lowering systolic BP to less than 120 mm Hg in this population, Cho and Lee said.

“There has to be an individualized approach when it comes to BP lowering,” Cho said. “If physicians expect more harms than benefits, that might be the reason why they are deferring systolic BP lowering below 120 mm Hg.”

“These patients are often older, have multiple comorbidities and they’re already taking multiple medications, so this target may not be achievable for a substantial proportion of patients,” Lee said. “Also, the standardized BP measurement on which the 2021 KDIGO BP guideline is based is often infeasible in clinical practice.”

Overall, the findings suggest adoption of the 2021 KDIGO BP guideline has remained stagnant, according to the researchers, who added that patients with systolic BP above the recommended target faced increased CVD and kidney failure risks.

“Regardless of what BP target they pursue, physicians should be aware of the evidence that intensive BP lowering is generally better on average,” Lee said. “Overall, it seems clear that BP control in this high-risk patient population remains very poor, and there’s still substantial room for improvement.”

“The 2025 ACC/AHA BP guidelines still maintain 130/80 mm Hg as the BP target, but they added a clause in which they encourage systolic BP lowering below 120 mm Hg whenever tolerated,” Cho said. “These guidelines and new BP-lowering trials are generally endorsing lower treatment targets unless adverse effects are likely. Our study is not endorsing one guideline over the other, but the findings clearly show that current practice is not well aligned with recent clinical trial data and guidelines.”

For more information:

So Mi Jemma Cho, PhD, can be reached at somi@broadinstitute.org.

Hyeok-Hee Lee, MD, PhD, can be reached at hlee43@bidmc.harvard.edu.