K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease


THE PUBLICATION of the Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification1 marked a milestone in the evolution of clinical practice guidelines and the delivery of care in nephrology. Specifically, these guidelines defined chronic kidney disease (CKD) and classified its stages, irrespective of underlying cause; evaluated laboratory measurements for the clinical assessment of kidney function; associated the level of kidney function with systemic complications that develop during progressive kidney disease; and stratified the risk for loss of kidney function and development of cardiovascular diseases in CKD.

In a broader sense, these guidelines emphasized that CKD is a worldwide public health problem with increasing incidence and prevalence, high cost, and poor outcomes. Importantly, they provided the framework for a public health approach to improve the quality of care and outcomes of all individuals with CKD. This is a major paradigm shift from the focus on dialysis care that has dominated the practice of nephrology, and was the focus of the initial clinical practice guidelines development process launched by the National Kidney Foundation in March 1995 as the Dialysis Outcomes Quality Initiative (DOQI).

Actually, it was in the course of developing DOQI guidelines that it became evident that, in order to further improve dialysis outcomes, it was necessary to first improve the health status of patients who end up requiring maintenance dialysis, and that therein existed an even greater opportunity to improve outcomes for all individuals with CKD, beginning at the earliest stages of kidney damage through the entire course of progressive loss of kidney function, well before kidney failure sets in and replacement therapy becomes necessary to sustain life. This is now feasible because of the accruing evidence that (1) the adverse outcomes of CKD (kidney failure, cardiovascular disease, premature death) can be prevented or delayed; (2) treatment of earlier stages of CKD is effective in retarding progression to kidney failure and in preventing the systemic complications that develop during the course of progressive CKD; and (3) initiation of therapy for cardiovascular risk factors at earlier stages of CKD can be effective in reducing the very high cardiovascular morbidity and mortality of these patients. Yet, the application of these medical advances remains inconsistent, resulting in variations in clinical practice and, sadly, avoidable poor outcomes. This is what prompted the expansion of the scope of DOQI to encompass the entire scope of CKD. To reflect this expansion, reference to "dialysis" in the acronym was changed to "disease" and the new initiative was termed Kidney Disease Outcomes Quality Initiative (K/DOQI), launched in January 2000.

The centerpiece of K/DOQI is the CKD guidelines on evaluation, classification, and stratification. The classification proposed in these guidelines constitutes the basis of K/DOQI interventional guidelines currently at various stages of development. The first of these to be completed was on the management of dyslipidemias in CKD, which was published as a supplement to the American Journal of Kidney Diseases (AJKD) in April 2003. The second was on the management of mineral and bone disorders in CKD also published as a supplement to the AJKD in October 2003. Another is the present set on hypertension and antihypertensive agents in CKD.

The CKD Guidelines (Guideline 7) specify high blood pressure as both a cause and a complication of CKD, which as a complication develops early in the course of CKD and is associated with adverse outcomes—in particular, faster loss of kidney function and development of cardiovascular disease. The evidence that appropriate management of hypertension and use of antihypertensive agents can slow the progression of kidney disease and reduce cardiovascular risk is overwhelming. Unfortunately, its clinical application to the care of patients is variable and far from optimal. It is to remedy this discrepancy that the present guidelines were developed.

This final version has undergone extensive revision in response to comments during the public review. While considerable effort has gone into their preparation over the past 2 years, and every attention has been paid to their detail and scientific rigor, no set of guidelines, no matter how well developed, achieves its purpose unless it is implemented and translated into clinical practice. Implementation is an integral component of the K/DOQI process and accounts for the success of its past guidelines. The K/DOQI Support Group is now developing implementation tools essential to the success of these guidelines.

In a voluntary and multidisciplinary undertaking of this magnitude many individuals make contributions to the final product now in your hands. It is impossible to acknowledge them individually here, but to each and every one of them we extend our sincerest appreciation, especially to the Advisory Board of K/DOQI and the Coordinating Board of the Global Guidelines Initiative, which in a joint session held in London in January 2003, reviewed and provided input to the initial draft of these guidelines. This broader review by international authorities represents the worldwide consensus being sought in developing guidelines, an effort subsequently reinforced by the review of these final guidelines by the blood pressure work groups of the European Best Practice Guidelines (EBPG). Thank you one and all for Making Lives Better for patients with CKD throughout the world. A special debt of gratitude is due to the members of the Work Group, their chair, Andrew S. Levey, and vice-chair, Michael V. Rocco. It is their commitment and dedication that has made it all possible.

Garabed Eknoyan, MD
K/DOQI Co-Chair

Adeera Levin, MD
K/DOQI Co-Chair

Nathan W. Levin, MD
K/DOQI Co-Chair Emeritus