Original Article
DOI:10.5301/JN.2011.6335
Hypertension management in chronic kidney
disease: translating guidelines into daily
practice
Luca De Nicola 1, Silvio Borrelli 1, Paolo Chiodini 2,
Pasquale Zamboli 1, Carmela Iodice 1,
Francis B. Gabbai 3, Giuseppe Conte 1,
Roberto Minutolo 1
Abstract
Background: Whether nephrology management im-
proves over time achievement of blood pressure (BP)
goal (<130/<80 mm Hg) in nondialysis CKD is still ill-
defined. This historical cohort analysis evaluated the
relationship between 1-year nephrology management
and BP control in 275 incident CKD patients in an aca-
demic renal clinic.
Methods: Comparative analysis between referral and
month-12 visit.
Results: Estimated glomerular filtration rate (GFR) was
42.1 ± 15.5 ml/min per 1.73 m2 and median proteinuria
0.20 g/24 hours. From baseline to month-12 visit, BP
decreased from 148 ± 23 / 81 ± 12 mm Hg to 136 ±
18 / 76 ± 11 mm Hg, with BP goal prevalence increas-
ing from 13.8% to 33.8%. We stratified patients into
at-goal and not-at-goal on the basis of month-12 BP
levels. Regression analysis identified diabetes (odds
ratio [OR] = 1.96; 95% confidence interval [95% CI],
1.07-3.56) and basal systolic BP (OR=1.12; 95% CI,
1.03-1.21) as independent predictors of not-at-goal
BP. The decrease in systolic/diastolic BP was smaller
in not-at-goal versus at-goal patients (-7/3 mm Hg vs.
-21/9 mm Hg); in not-at-goal reduction was, however,
significant versus baseline (p<0.001) and coupled with
a similar decline in proteinuria (p<0.001).
© 2011 Società Italiana di Nefrologia - ISSN 1121-8428
JNEPHROL 2011; 24 ( 06 ) : 733-741
Division of Nephrology, Second University of Naples,
1
Naples - Italy
Department of Biostatistics, Second University of Naples,
2
Naples - Italy
Division of Nephrology, University of California in San
3
Diego, San Diego, California - USA
Conclusions: Sustained nephrology management im-
proves hypertension control in CKD, but achievement
of BP goals remains suboptimal, with high systolic BP
and diabetes being the main problems. Further stud-
ies are needed to verify the clinical significance of BP
and proteinuria changes in patients whose BP remains
above target levels.
Key words: Antihypertensive treatment, Blood pres-
sure goal, Chronic kidney disease, Hypertension, Salt
intake
Introduction
Correction of hypertension is a major therapeutic goal
in nondialysis chronic kidney disease (CKD). High blood
pressure (BP) in fact is the most frequent complication
of CKD (1), acts as a determining factor in the progres-
sion of renal damage (2-7) and contributes to greater
cardiovascular (CV) risk (5, 7-9). Accordingly, clinical
practice guidelines (CPGs) recommend strict BP con-
trol – that is, to less than 130/80 mm Hg – by means
of intensified therapy (10-13). However, cross-sectional
studies have shown that BP goals are reached in only
733
De Nicola et al: Blood pressure control in CKD
10%-25% of CKD patients followed in the real world of
clinical practice (14-23). Surprisingly, this picture does
not substantially change in nephrology clinics (16-20,
23). Such a discouraging finding may either be the con-
sequence of undertreatment in the specialist setting or
evidence of resistance to antihypertensive intervention
in the unselected patients commonly seen in the dai-
ly practice. This critical question has remained unan-
swered so far because cross-sectional studies do not
assess the effect of therapy intensification on achieve-
ment of BP targets.
We therefore designed this longitudinal study to evaluate
the relationship between BP management and BP control in
an incident cohort of hypertensive nondialysis CKD patients
over their first year of follow-up in an academic renal clinic.
Subjects and methods
This is a historical cohort study using a prospective da-
tabase that included all consecutive patients incident in
the outpatient clinic of the Department of Nephrology
at the Second University of Naples, Italy. The database
provided comprehensive and detailed information on de-
mographic, clinical, laboratory, therapeutic features and
presence or absence of left ventricular hypertrophy (LVH)
and history of CV disease (hospitalization for coronary
heart disease, cerebrovascular and peripheral vascular
disease). All patients were referred to the clinic by the
general practitioners (GPs) working in the same area as
our hospital. Clinical and laboratory data were collected
at baseline and month-12 visit. Baseline treatment was
that prescribed by the GP; from then on, treatment was
that prescribed by the nephrologist in clinic. The study
was approved by the institutional review board, and all
patients gave informed consent to use of their data.
Patients
We considered eligible for the study all consecutive inci-
dent patients who were not on dialysis and without a kidney
transplant, who were referred by a GP from June 1, 2004,
to May 31, 2007, because of diagnosis of CKD, defined as
an estimated glomerular filtration rate (eGFR) <60 or ≥60
ml/min per 1.73 m2, plus proteinuria >0.3 g/24 hours in 2
consecutive visits with an interval ≥3 months, and who had
completed at least 1 year of follow-up in our clinic. Patients
were excluded if at the first visit, BP was <130/80 mm Hg
without antihypertensive therapy, there was evidence of
acute kidney injury, active malignancy, advanced liver dis-
ease or active steroid or immunosuppressive therapy use.
734 © 2011 Società Italiana di Nefrologia - ISSN 1121-8428
Standards for CKD care
In our clinic, each patient was seen by the same nephrolo-
gist at all visits, the frequency of which was determined
based on the K/DOQI guidelines and the clinical status of
the patient. Each participating nephrologist is well versed
in, and committed to, the goals of hypertension treat-
ment recommended by the K/DOQI guidelines (10, 12). In
particular, BP treatment is aimed at reaching the recom-
mended goal (systolic BP <130 mm Hg and diastolic BP
<80 mm Hg).
Laboratory protocols were standardized with in-house
analysis of blood and urinary samples, including measure-
ment of creatinine by modified kinetic Jaffé reaction, and
proteinuria by the pyrogallol red-molybdate method. GFR
was estimated by the 4-variable Modification of Diet in
Renal Disease (MDRD) Study equation. Twenty-four-hour
urine collection was obtained at each visit where protein-
uria was quantified. This urine collection was also used to
evaluate the adherence to the routinely prescribed restric-
tion of dietary salt (<6 g NaCl/day) and protein (≤0.8 g/kg
body wt/day) by means of urinary excretion of Na (UNaV)
and urea. The collection was considered inaccurate, and
repeated, if the creatinine excretion was outside of the
60% to 140% range of the value calculated according to
Dwyer and Kenler (24).
Body weight and BP were recorded at each visit. BP
measurement was performed by the nephrologist in a
quiet environment in the morning using a mercury sphyg-
momanometer with a cuff size of appropriate dimension
and with the patient in a sitting position after 10 minutes
of rest. The first and fifth Korotkoff sounds were used to
define systolic and diastolic BP values, respectively; the
mean of 3 consecutive readings taken 2 minutes apart
was considered for analysis.
The patients who did not achieve the BP goal were screened
for secondary causes of hypertension other than CKD. Ad-
herence to the prescribed drug therapy was also checked at
each visit by means of specific questions to the patient and
family members. A patient was considered poorly compliant
when pharmacological therapy differed from prescription in
at least 2 follow-up visits. Efforts to minimize poor adher-
ence included dedicated time at each visit to remind the pa-
tient and his/her family members of the high risk associated
with CKD and the benefits of compliance with therapy.
Statistical analysis
Continuous variables are reported as either means ± SD or
median and interquartile (IQR) range on the basis of their
 JNEPHROL 2011; 24 ( 06 ) : 733-741

distribution (assessed using Shapiro-Wilk test). Compari-

sons of variables between basal and 12-month were per-
formed using either paired Student’s t-test or Wilcoxon test
on the basis of the variable’s distribution. Similarly, for sub-
group analyses we used either unpaired Student’s t-test or
Mann-Whitney test. Categorical variables are expressed as
percentages and analyzed by chi-square test or by McNe-
mar test for paired comparisons. A patient was identified as
being at-goal when BP <130/80 mm Hg, and not-at-goal if
systolic blood pressure ≥130 mm Hg and/or diastolic blood
pressure ≥80 mm Hg. Multivariable logistic regression anal-
ysis was performed to investigate factors associated with
lack of achievement of BP goals at month-12 visit within
the entire cohort. The model was built a priori by including
all the covariates potentially acting as confounders besides
the demographic characteristics.
A 2-tailed p value <0.05 was considered significant. Data
were analyzed using SPSS, version 12.0 (SPSS Inc, Chi-
cago, IL, USA).
Fig. 1 - Frequency of multidrug therapy in the study cohort
(white columns) and in at-goal (gray columns) and not-at-
Results goal (black columns) subgroups at baseline (top panel) and
at month-12 visit (bottom panel). Goal was defined as blood
pressure <130/80 mm Hg.
Out of the 335 eligible patients, 275 were included in the
study on the basis of the selection criteria. All patients
were whites. At the time of referral, patients had been fol-
lowed by their GP for at least 1 year. No secondary cause As described in Table I, BP control at the time of referral
of hypertension other than CKD was found. Mean age appeared heterogeneous, with the targets being achieved
was 67.5 ± 11.3 years, prevalence of male sex and active more sporadically in females, obese patients, in those free
smoking was 60.4% and 21.5%, respectively. The leading from CV disease and in mild CKD. In contrast, management
causes of CKD were hypertensive nephropathy (52.0%) by the nephrologists increased the prevalence of BP at-goal
and diabetic nephropathy (22.5%). At baseline, mean se- above 30% in all but diabetic patients.
rum creatinine was 1.83 ± 0.22 mg/dL and GFR was 42.1 Increased prevalence of BP at-goal required an increase in
± 15.5 ml/min per 1.73 m2. Median proteinuria was 0.20 the number of antihypertensive agents (from 2.4 ± 1.3 to
g/24 hours, with levels ≥1.0 g/24 hours in 23% of patients. 3.1 ± 1.3, p<0.0001) and in the use of polytherapy (Fig. 1).
The cohort was characterized by a high CV risk profile While at baseline, 1 out of 4 patients was taking 0-1 drug
as evidenced by the high prevalence rates of diabetes and 10 patients were untreated, by the end of study, all
(39.6%), CV disease (41.5%) and LVH (62.9%). patients were taking antihypertensive medication and two
In the whole cohort, systolic and diastolic BP values thirds had been prescribed 3 or more agents (65.8% vs.
markedly decreased during follow-up (from 148 ± 23 / 81 46.6% at baseline). Inhibitors of the renin-angiotensin sys-
± 12 mm Hg to 136 ± 18 / 76 ± 11 mm Hg). A substantial tem (RAS) were the most frequently prescribed agent from
BP reduction was already observed at month 6, when the first to the last visit (angiotensin-converting enzyme in-
BP was 141 ± 18 / 78 ± 11 mm Hg. The prevalence of hibitor [ACEI]: 58% to 64%; angiotensin II receptor blocker,
BP at-goal concurrently increased from 13.8% at refer- [ARB]: 29% to 44%), with only 8.7% of patients not taking
ral, to 33.8% at month 12, with the systolic target being any RAS inhibitor by the end of study. Intensification of fu-
achieved less frequently than the diastolic one (systolic rosemide therapy was an additional intervention of neph-
BP <130 mm Hg: from 17.5% to 38.5%, diastolic BP rologists, as testified by the increased use in not-at-goal
<80 mm Hg: from 36.4% to 58.5%). Therefore, after 12 patients and the increment of doses in either subgroup of
months of follow-up in the renal clinic, 93 patients had patients (Tab. II). In contrast, the obtained adherence to the
BP <130/80 mm Hg (at-goal group), while 182 had BP recommended salt intake (<6 g/day) was inadequate, as
≥130/80 mm Hg (not-at-goal group). evidenced by a sodium excretion less than 100 mEq/24

© 2011 Società Italiana di Nefrologia - ISSN 1121-8428 735

De Nicola et al: Blood pressure control in CKD

hours in only 23% of the patients by the end of the study.
Poor compliance with drug therapy was infrequent in the
not-at-goal patients (4.4%). Conversely, significant dif-
ferences were observed in the baseline characteristics
of the patients reaching and not reaching the BP goal at
month-12 visit. The not-at-goal group was in fact charac-
terized by greater body mass index (calculated as kg/m2:
30.2 ± 6.2 vs. 28.7 ± 4.5; p=0.04), higher prevalence of
diabetes (44.5% vs. 30.1%, p=0.02) and higher systolic
and diastolic BP at baseline (Tab. II). Conversely, age, sex,
smoking habit, previous CV disease, presence of LVH and
distribution of underlying kidney diseases were similar in
the 2 subgroups (data not shown). After adjustment for
potential confounders by logistic regression analysis, dia-
betes and systolic BP emerged as the only factors inde-
pendently associated with the lack of achievement of BP
targets at month 12 (Tab. III).
In not-at-goal patients, the decrease in systolic/diastolic BP

TABLE I
SUBGROUP ANALYSIS OF BLOOD PRESSURE CONTROL (<130/80 mm Hg) AT REFERRAL AND LAST VISIT IN THE
RENAL CLINIC

Baseline Month 12
% (95% CI) % (95% CI)

Overall (n=275) 13.8 (9.7-17.9) 33.8 (28.2-39.4)

Age
≤65 years (n=98) 12.2 (5.8-18.7) 32.7 (23.4-41.9)
>65 years (n=177) 14.7 (9.5-19.9) 34.5 (27.5-41.5)

Sex
Female (n=109) 9.2 (3.8-14.6) 30.3 (21.6-38.9)
Male (n=166) 16.9 (11.2-22.6) 36.1 (28.8-43.5)
Obesity*
No (n=167) 17.4 (11.6-23.1) 35.3 (28.1-42.6)
Yes (n=108) 8.3 (3.1-13.6) 31.5 (22.7-40.2)
Diabetes
No (n=166) 14.5 (9.1-19.8) 39.2 (31.7-46.6)
Yes (n=109) 12.8 (6.6-19.1) 25.7 (17.5-33.9)

Cardiovascular disease
No (n=161) 10.6 (5.8-15.3) 35.4 (28.0-42.8)
Yes (n=114) 18.4 (11.3-25.5) 31.6 (23.0-40.1)

CKD stage
Stage 2 (n=28) 3.6 (3.3-10.4) 35.7 (18.0-53.5)
Stage 3a (n=80) 16.3 (8.2-24.3) 35.0 (24.5-45.5)
Stage 3b (n=108) 13.0 (6.6-19.3) 34.3 (25.3-43.2)
Stage 4-5 (n=59) 16.9 (7.4-26.5) 30.5 (18.8-42.3)

Data are percentages of patients and (95% confidence interval).

CKD = chronic kidney disease.
*Obesity is defined as body mass index (calculated as kg/m2) ≥30.

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 JNEPHROL 2011; 24 ( 06 ) : 733-741

TABLE II
CHANGES IN MAIN CLINICAL, LABORATORY AND THERAPEUTIC CHARACTERISTICS FROM BASAL TO MONTH-12
VISIT IN PATIENTS AT-GOAL AND NOT-AT-GOAL

At-goal Not-at-goal
(n=93) (n=182)

Baseline Month 12 Baseline Month 12

eGFR, ml/min per 1.73 m2 42.3 ± 15.6 42.7 ± 17.2 41.9 ± 15.5 40.7 ± 17.1

Proteinuria, g/24 hours 0.23 (0.10-0.89) 0.15 (0.04-0.52)* 0.20 (0.10-0.85) 0.17 (0.03-0.55)*

Urinary Na, mEq/24 hours 150 ± 64 149 ± 57 155 ± 69 160 ± 75

Systolic BP, mm Hg 140 ± 21 119 ± 7* 152 ± 23† 146 ± 15*

Diastolic BP, mm Hg 78 ± 11 69 ± 7* 83 ± 12† 80 ± 11*

BP drugs, no. 2.3 ± 1.3 2.8 ± 1.2* 2.5 ± 1.2 3.2 ± 1.3*‡

ACEI and/or ARB, % 76.3 91.4* 80.2 91.2*

CCB, % 38.7 40.9 45.6 55.5‡§

Beta blockers, % 19.4 32.3* 36.3† 40.7

Alpha blockers, % 7.5 17.2* 6.0 16.5§

Thiazides, % 24.7 25.8 31.9 35.2

Furosemide, % 30.1 38.7 28.0 42.3*

Furosemide, mg/day 37 ± 29 59 ± 33§ 38 ± 35 64 ± 49§

Data are expressed as means ± SD, and as % or median (IQR). Goal defined as month-12 blood pressure <130/80 mm Hg.
ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor antagonist; BP = blood pressure; CCB =
calcium channel blockers; eGFR = GFR value by the 4-variable MDRD equation; Na = sodium.
*p<0.001, vs. baseline.
†
p<0.005, vs. at-goal.
‡
p<0.05, vs. at-goal.
§
p<0.05, vs. baseline.

© 2011 Società Italiana di Nefrologia - ISSN 1121-8428 737

De Nicola et al: Blood pressure control in CKD

of analogous median number of visits (n=6, IQR 5-8, in at-

goal group; and n=7, IQR 5-9, in not-at-goal group), similar
changes in the antihypertensive regimen (Tab. II and Fig. 1)
and similar increases in the use of combined ACEI+ARB
therapy (from 7% to 17% in not-at-goal group and from 10%
to 16% in at-goal group). Mean UNaV remained constantly
high in both groups (Tab. II), reflecting the poor adherence to
salt restriction in either group.

Fig. 2 - Reduction of systolic (dotted columns) and diastolic
blood pressure (white columns), and proteinuria (black col-
umns), from baseline to month-12 visit in patients at-goal and
not-at-goal (goal defined as month-12 blood pressure <130/80
mm Hg). BP = blood pressure; Uprot = urinary protein.
values was smaller compared with that in the at-goal group,
but it was associated with a similar reduction of proteinu
In not-at-goal patients, the decrease in systolic/diastolic BP
values was smaller compared with that in the at-goal group,
but it was associated with a similar reduction of proteinuria
(Fig. 2). The difference in BP response was observed in spite
Discussion
We found that exposure to nephrology care increased the
prevalence of BP goal attainment, from 14% obtained in GP
offices, to 34% registered at the end of follow-up in our renal
clinic. The observed rates of BP control were definitely bet-
ter than those described in previous cross-sectional surveys
in CKD patients (14-23). In particular, the control rate ob-
tained in our clinic was almost threefold higher when com-
pared with data from the multicenter cross-sectional survey
we recently conducted in CKD patients prevalent in Italian
renal clinics (17). The observed improvement in BP control
also held true when examining another previous cross-sec-
tional analysis comparing BP management in our clinic and
that in the GP offices in our area (18). In that study, optimal
BP control was registered in 20% of our patients and 6% of
patients exclusively seen by a GP.
In the GP offices, achievement of the BP goal, even though

TABLE III
LOGISTIC REGRESSION ANALYSIS OF BASAL PREDICTORS OF NOT-AT-GOAL STATUS (MONTH-12 BLOOD PRES-
SURE ≥130/80 mm Hg)

Factor Odds ratio 95% Confidence interval p Value

Age, year 0.99 0.96-1.02 0.613

Male sex 0.92 0.49-1.70 0.780
Body mass index (calculated as kg/m2) 1.04 0.98-1.09 0.190
Diabetes 1.96 1.07-3.56 0.029
Hypertension length, years 1.02 0.98-1.05 0.339
History of CVD 1.32 0.74-2.35 0.353
eGFR, 5 ml/min per 1.73 m2 0.99 0.91-1.09 0.893
Proteinuria, g/24 hours 0.94 0.79-1.12 0.474
Systolic BP, 5 mm Hg 1.12 1.03-1.21 0.010
Diastolic BP, 5 mm Hg 1.13 0.97-1.32 0.128

BP = blood pressure; CVD = cardiovascular disease; eGFR = GFR value by 4-variable MDRD equation.

738 © 2011 Società Italiana di Nefrologia - ISSN 1121-8428


improved with respect to the past (18), was largely insuffi-
cient. Similar results have recently been reported in a large
sample of UK patients (22), where primary care providers
failed to achieve the BP goal (<130/80 mm Hg) in stage
3-5 CKD patients about 90% of the time, in spite of ac-
cess to computerized assessment of CKD. The problems
with management of BP in the GP setting underscore the
need for integrated care from the early stages of CKD. As
recently pointed out by Hallan and Stevens (25), high-risk
groups such as patients with diabetes mellitus or hyper-
tension and those above age 60 should have their GFR
estimated and be tested for albuminuria in GP offices and,
if correctly identified as having CKD on the basis of these
2 parameters, they should become the first candidates for
integrated management. The need for an early integrated
approach is further supported by the observation that our
intervention consistently improved the limited and hetero-
geneous BP control detected at referral. Indeed, we over-
came the failure of GPs in controlling BP possibly due to
underestimation of the hypertension problem, as in the
case of mild CKD, female sex, absence of CV disease,
or in the presence of hard-to-treat hypertension as in the
case of obesity (Tab. I).
Although nephrology care markedly reduced BP levels
as compared with that in GP offices, about 66% of the
patients remained with BP ≥130/80 mm Hg by the end
of nephrology follow-up in spite of the strict monitor-
ing and intensification of drug therapy. Of interest, BP
control was more difficult in patients carrying greater CV
and renal risk, such as diabetics and those with higher
systolic BP at baseline (Tab. III). This finding stresses
the fact that the paradoxical association between higher
risk and worse BP control, previously reported by cross-
sectional studies in renal and nonrenal patients followed
in specialist practices (17, 26), persists after sustained
exposure to therapy intensification.
The retrospective nature of our study design precludes
us from generating definitive conclusions regarding the
mechanism for why BP goal is so difficult to achieve in
high-risk patients treated in a renal clinic. Nevertheless,
we can reasonably exclude the potential role of poor com-
pliance to therapy in most patients, which constitutes a
major weakness in the management of BP in primary care
(27) but is less common in the specialist setting (28), espe-
cially when the frequency of control visits is as high as in
our cohort. Similarly, underuse of diuretics, and in particu-
lar of furosemide, which are the first-choice antihyperten-
sive drugs in CKD especially in the absence of adequate
compliance to a low salt diet (29), may also be excluded
(Tab. II). Hence, diabetes and severe hypertension emerge
© 2011 Società Italiana di Nefrologia - ISSN 1121-8428
JNEPHROL 2011; 24 ( 06 ) : 733-741
as the main features associated with refractory hyperten-
sion in CKD. Under these conditions, BP elevations may
be more difficult to control due to severe vascular damage
and resulting vasoconstriction (11, 13, 30, 31).
An important finding of our study is the small but significant
reduction in BP of 7/3 mm Hg in those individuals with BP
not-at-goal when such reduction is coupled with a simulta-
neous reduction in proteinuria (Fig. 2). Indeed, reductions
in BP of similar magnitude are significant to prevent CV
events in high-risk patients like those in our cohort (11, 13,
32). More important, both CV and renal prognosis further
improve when proteinuria reduction is coupled with a de-
crease in BP (6, 33), even in patients with low-range protei-
nuria (34), as in the case of our cohort.
In conclusion, the transition of management from primary to
tertiary nephrology care consistently decreased BP levels,
and allowed the achievement of the recommended BP goal
of less than 130/80 mm Hg in more than one third of our
CKD patients. Baseline high systolic BP levels and diabetic
status emerged as the main barriers to further amelioration
of BP control. Prospective studies in larger samples of un-
selected regular CKD patients are required to verify whether
the mild but significant reductions in BP and proteinuria in
the patients who remained above goal herald better cardio-
renal outcomes.
A portion of the study was presented and published as an abstract
(J Am Soc Nephrol. 2008;19:307A), at the 2008 Renal Week of the
American Society of Nephrology.
Financial support: This work was partially supported by an Italian
government grant from the Health Minister (Ricerca Sanitaria
2006: attività di ricerca finalizzata-articolo 12), Rome, Italy, to
L.D.N. in 2006.
Conflict of interest statement: There is no conflict of interest to
declare.
Address for correspondence:
Prof. Luca De Nicola
Cattedra di Nefrologia
Dip. Gerontologia, Geriatria
Mal. Metabolismo
Seconda Università di Napoli
Piazza Miraglia
IT-80131 Napoli, Italy
luca.denicola@unina2.it
739
De Nicola et al: Blood pressure control in CKD
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Accepted: November 12, 2010
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