Table 6.
Clinical guidelines for modification of CV risk factors in CKD patients.
| Risk Factor | ACC/AHA | KDIGO | KDOQI |
|---|---|---|---|
| NDD-CKD | |||
| BP target | <130/80 (B)91 | ≤140/90 if no albuminuria (1B)92 ≤130/80 if albuminuria ≥30 mg/24 h (2D)92 | <130/80 (B)93 |
| BP medication choice | Use ACEi/ARB (B)91 | ACEi/ARB in DM pts with albuminuria ≥30 mg/24 h (2D)92 ACEi/ARB in non-DM pts with albuminuria ≥300 mg/24 h or equivalent (1B)92 | Other than ACEi/ARB for albuminuric pts, RCT evidence does not support specific recommendations (NR)93 |
| Aspirin | Low-dose aspirin should be used in DM pts with albuminuria or other CV risk factors (B)94 | Aspirin is indicated for secondary but not primary prevention (2B)92 | – |
| Lipid management | No specific recommendation for CKD; initiate high intensity statin if ≤75 y for secondary prevention, including for CKD subgroup (low)95 | Give statin if ≥50 y (1A-1B)96 Give statin if known CAD, DM, prior ischemic stroke, or estimated 10-y CVD risk >10% (2A)96 | Add to KDIGO guidelines to treat pts with <50 y and LDL ≥190 mg/dL with high intensity statins, as recommended by ACC/AHA (NR)97 |
| Glycemic control | Target HbA1c to < or ~7.0% (A)98 | Target HbA1c to ~7.0% (1A)92 | Target HbA1c <7.0% (A)99 |
| Smoking | No specific recommendations for CKD; smoking avoidance and cessation for all (NR) | Smoking cessation is an important modifiable CV risk factor (1D)92 | No evidence in CKD, but recommend smoking cessation as it is a CV risk factor (NR)93 |
| Weight loss | No specific recommendations for CKD; advise overweight and obese adults that the greater the BMI, the greater risk of CV disease, T2DM, and death (A)100 | Target BMI 20-25 (1D)92 | – |
| Physical activity | No specific recommendations for CKD; moderate to vigorous aerobic exercise 3–4×/wk, lasting ~40 min per session (B)101 | Goal physical activity 30 min 5×/wk as tolerated by CV health (1D)92 | RCTs in general population support exercise and there is little evidence that NDD-CKD patients may respond differently (NR)93 |
| CKD-5D | |||
| BP target | – | Aggressively treat pre-dialysis SBP ≥200; BP associated with minimal risk unknown; only study published showed best outcome for home SBP 120-145 (NR)102 | Pre-dialysis BP <140/90, post-dialysis BP <130/80 (C)103 |
| BP medication choice | – | No compelling evidence to recommend one class of anti-HTN agents over another (not rated)102 | ACEi/ARB preferred (greater LVH regression; reduce sympathetic nerve activity and PWV; may improve endothelial function and reduce oxidative stress) (C)103 |
| Aspirin | – | – | – |
| Lipid management | – | Statins should not be initiated, but should be continued if the pt is already treated (2C)96 | Add to KDIGO guidelines to consider statin initiation if recent acute coronary event, young age or long life expectancy, or on transplant wait-list (not rated)97 |
| Glycemic control | – | – | Dialysis pts with DM should follow the ADA guidelines (C)103 |
| Smoking | – | – | All dialysis pts should be counseled and regularly encouraged to stop smoking (A)103 |
| Weight loss | – | – | Safety and efficacy of weight loss in the overweight dialysis pt is unknown, as is the potential benefit to CV outcomes (NR)103 |
| Physical activity | – | – | Counsel and encourage all dialysis pts to increase their physical activity (B)103 Goal for activity is for CV exercise at moderate intensity for 30 min most, if not all, d/wk (C)103 |
The information in this table was adapted in summary form from published guidelines from the American College of Cardiology and American Heart Association (ACC/AHA), Kidney Disease: Improving Global Outcomes (KDIGO), and Kidney Disease Outcomes Quality Initiative (KDOQI). Quality of evidence is presented in parentheses
ACC/AHA: A, data from multiple randomized clinical trials; B, data from one randomized trial or nonrandomized studies; C, expert opinion
KDIGO: 1, recommended; 2, suggested; A, high quality; B, moderate quality; C, low quality; D, very low quality
KDOQI: A, strongly recommended and based on strong evidence; B, recommended and based on moderately strong evidence; C, recommended based on weak evidence or expert opinion
Abbreviations: ACC, American College of Cardiology; ACEi, angiotensin converting enzyme inhibitor; ADA, American Diabetes Association AHA, American Heart Association; ARB, angiotensin receptor blocker; BMI, body mass index (in kg/m2); CAD, coronary artery disease; CKD-5D, dialysis-dependent chronic kidney disease; CV, cardiovascular; HbA1c, hemoglobin A1c; KDIGO, Kidney Disease: Improving Global Outcomes; KDOQI, Kidney Disease Outcomes Quality Initiative; LDL, low density lipoprotein; LVH, left ventricular hypertrophy; NDD-CKD, non-dialysis-dependent chronic kidney disease; SBP, systolic blood pressure; NR, not rated; BP, blood pressure (given in mm Hg); DM, diabetes mellitus; T2DM, type 2 diabetes mellitus; PWV, pulse wave velocity; HTN, hypertension; pts, patients; CVD, cardio vascular disease