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## Complete Summary

#### GUIDELINE TITLE

K/DOQI clinical practice guidelines on hypertension and antihypertensive
agents in chronic kidney disease.

#### BIBLIOGRAPHIC SOURCE(S)

K/DOQI clinical practice guidelines on hypertension and antihypertensive
agents in chronic kidney disease. Am J Kidney Dis 2004 May;43(5 Suppl
1):S1-290. \[625 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15114537)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Hypertension

-   Chronic kidney disease, including:

    -   Diabetic kidney disease

    -   Nondiabetic kidney diseases including glomerular diseases,
        vascular diseases, tubulointerstitial diseases, and cystic
        diseases

    -   Kidney disease in the kidney transplant recipient

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine\
Nephrology\
Nutrition\
Pediatrics\
Pharmacology

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dietitians\
Health Care Providers\
Nurses\
Pharmacists\
Physician Assistants\
Physicians\
Social Workers

#### GUIDELINE OBJECTIVE(S)

To develop evidence-based recommendations for the evaluation and
management of hypertension and use of antihypertensive agents in chronic
kidney disease (CKD)

#### TARGET POPULATION

Adults or children with chronic kidney disease (CKD) Stages 1-4 (as
defined by the Kidney Disease Outcomes Quality Initiative \[K/DOQI\]
Guidelines on CKD).

**Note**: These guidelines are [not]{.underline} intended for patients
with CKD Stage 5 (kidney failure).

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation/Risk Assessment**

Initial evaluation and re-evaluations based on clinical condition

1.  Measurement of blood pressure (casual blood pressure \[CBP\]),
    self-measured blood pressure (SMBP), or ambulatory blood pressure
    monitoring (ABPM)

2.  Type of chronic kidney disease (CKD) (diagnosis), level of
    glomerular filtration rate (GFR), level of proteinuria

3.  Laboratory measurements for all patients at increased risk for CKD,
    including serum creatinine to estimate GFR; albumin-to-creatinine or
    protein-to-creatinine ratio in a first-morning or random untimed
    urine specimen; examination of the urine sediment or dipstick for
    red blood cells and white blood cells

4.  Laboratory measurements for patients found to have CKD, including
    imaging of the kidneys, usually by ultrasound; serum electrolytes

5.  Laboratory measurements for ascertainment of cardiovascular disease
    (CVD) and CVD risk factors in CKD: 12-lead electrocardiogram (EKG);
    serum glucose, fasting lipid panel; height and weight to calculate
    body mass index (BMI)

6.  Complications of decreased GFR

7.  Risk for progression of kidney disease

8.  Presence of clinical CVD and CVD risk factors

9.  Presence of comorbid conditions

10. Estimation of probability of renal artery disease (RAD) (predictive
    index derived from clinical characteristics; noninvasive screening
    test for RAD)

11. Barriers to self-management, adherence to diet and other lifestyle
    modifications, and adherence to pharmacological therapy

12. Complications or side effects of pharmacological therapy

**Management/Treatment/Secondary Prevention**

1.  Development of clinical action plan based on the stage of CKD

2.  Establishment of target blood pressure

3.  Referral to specialists as indicated

4.  Coordination with multiple therapies as part of a multi-intervention
    strategy

5.  Patient and family education that is culturally sensitive, sensitive
    to economic considerations, and based on the patient\'s level of
    understanding (how to measure and record blood pressure;
    self-management behavior; anti-hypertensive therapy)

6.  Lifestyle modifications to lower blood pressure and reduce risk of
    cardiovascular disease (diet; non-dietary approaches, such as weight
    control, exercise, moderation of alcohol, smoking cessation)

7.  Pharmacologic therapy to slow progression of kidney disease

    -   Angiotensin-converting enzyme (ACE) inhibitors (Benazepril
        \[Lotensin\], Captopril \[Capoten\], Enalapril \[Vasotec\];
        Fosinopril \[Monopril\]; Lisinopril {Prinivil, Zestril\];
        Moexipril \[Univasc\]; Perindopril \[Aceon\]; Quinapril
        \[Accupril\]; Ramipril \[Altace\]; Trandolapril \[Mavik\]

    -   Angiotensin-receptor blockers (ARBs) (Candesartan \[Atacand\];
        Eprosartan \[Teveten\]; Irbesartan \[Avapro\]; Losartan
        \[Cozaar\]; Olmesartan \[Micardis\]; Telmisartan \[Micardis\];
        Valsartan \[Diovan\])

8.  Other pharmacologic agents to reduce cardiovascular risk and/or
    achieve blood pressure goals

    -   Diuretics, including thiazide-type diuretics, loop diuretics,
        potassium-sparing diuretics

    -   Beta-blockers, including non-selective beta-blockers, selective
        beta blockers, combined alpha and beta blockers

    -   Calcium-channel blockers, including dihydropyridines and
        nondihydropyridines

    -   Alpha-adrenergic blockers

    -   Direct acting vasodilators

    -   Aldosterone antagonists

    -   Combination therapy

9.  Strategies to improve adherence to pharmacologic therapy

10. Ongoing monitoring and evaluations (see \"Evaluation\" section
    above)

11. Interventions specific to children

#### MAJOR OUTCOMES CONSIDERED

-   Direct health outcomes related to kidney disease progression (kidney
    failure, changes in glomerular filtration rate \[GFR\], changes in
    serum creatinine, mortality)

-   Surrogate outcome related to kidney disease progression
    (proteinuria)

-   Direct health outcomes related to cardiovascular disease (CVD)
    (clinical events, cause-specific mortality, total mortality)

-   Surrogate outcomes related to CVD (left ventricular hypertrophy or
    carotid artery intima thickness)

-   Incidence of adverse effects of drug treatment

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Existing Guidelines on Chronic Kidney Disease (CKD)**

There were several prior guideline recommendations for blood pressure
management in chronic kidney disease (CKD), as well as other documents
that became available during the course of guideline development and
these were reviewed by the Work Group. The recommendations issued in
1997 by the Sixth Joint National Commission (JNC 6) were considered a
reference source. Thus, the search for other guidelines with
recommendations on blood pressure management in CKD was restricted to
guidelines published since 1997. Searches were conducted through the
National Guideline Clearing House on the following keywords:
hypertension, kidney disease, diabetes, and cardiovascular disease,
spanning the time from 1997 until March 2003. Approximately 150
guideline citations were found. All guidelines that could be downloaded
free of charge or retrieved from published medical journals were
searched for recommendations for blood pressure management and use of
antihypertensive agents in CKD. Through this search, guideline
developers found 11 guidelines with pertinent sections and supplemented
this with other known recommendations.

**Existing Guidelines on Cardiovascular Disease (CVD) in the General
Population**

The same search that was conducted through the National Guideline
Clearinghouse to identify existing guidelines with recommendations on
managing blood pressure in CKD (see above) was also screened for
sections containing recommendations on risk reduction for CVD using
antihypertensive agents. This yielded 13 guidelines which were
abstracted and compiled into tables and reviewed by Work Group experts.

**Literature Search of Primary Articles**

The Work Group and Evidence Review Team decided in advance that a
systematic process would be followed to identify primary studies on the
topics of interest. Only fully published articles with original data
were included. Review articles, editorials, letters or abstracts were
generally excluded. The only exceptions were abstracts of the ALLHAT
trial reporting kidney disease progression and CVD outcomes in a large
subgroup of individuals with CKD. The Work Group members and Evidence
Review Team selected textbooks and review articles based on personal
knowledge.

Studies for the literature review were identified primarily through
Medline searches of the English language literature. The Medline
literature searches were conducted between July 2001 and July 2002 to
identify clinical studies published from 1966 through the search dates.
Separate search strategies were developed for each topic.

Development of the search strategies was an iterative process that
included input from all members of the Work Group. The text words or
medical subject headings (MeSH) included kidney or kidney diseases or
kidney function tests or hypertension or renal, diabetic nephropathy,
renal artery, and ambulatory blood pressure monitoring. The searches
were limited to human studies. Studies that focused on hemodialysis or
peritoneal dialysis, pregnancy, neonates, malignant hypertension, acute
renal failure, or pharmacokinetics were excluded.

The Evidence Review Team screened citations identified by the Medline
search. Potentially relevant articles were identified from abstracts and
titles, based on study population, relevance to specific guideline
topics, and the study design. In general, studies with fewer than 10
subjects per treatment arm were excluded. However, for pediatric topics,
due to the small number of articles, only case reports were excluded.
Relevant articles known to domain experts and reviewers supplemented
these searches. After retrieval, each paper was screened according to
the established criteria to verify its relevance and appropriateness.
Work Group members assigned to the specific topic reviewed the articles
and made the final decision for inclusion or exclusion of articles.
However, they had to provide the reason for rejection. Data extraction
was performed on all included articles and their data compiled into
evidence tables. Additional relevant studies published since July 2002
were added by experts.

#### NUMBER OF SOURCE DOCUMENTS

-   Primary articles

    -   Abstracts screened = 11,688

    -   Articles retrieved and reviewed = 899

    -   Articles where data were extracted = 177

    -   Articles added by Work Group = 47

    -   Articles systematically reviewed and listed in summary tables =
        76

-   Existing guidelines on chronic kidney disease (CKD): 18 guidelines

-   Existing guidelines on cardiovascular disease (CVD) in the general
    population: 13 guidelines

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Strong**

Evidence includes results from well-designed, well-conducted
study/studies in the target population that directly assesses effects on
health outcomes.

**Moderately Strong**

Evidence is sufficient to determine effects on health outcomes in the
target population, but the strength of the evidence is limited by the
number, quality, or consistency of the individual studies; OR evidence
is from a population other than the target population, but from
well-designed, studies on surrogate endpoints for efficacy and/or safety
in the target population.

**Weak**

Evidence is insufficient to assess the effects on net health outcomes
because it is from studies with some problems in design and/or analysis
on surrogate endpoints for efficacy and/or safety in the target
population; OR the evidence is only for surrogate measures in a
population other than the target population; OR the evidence is from
studies that are poorly designed and/or analyzed.

The strength of evidence for a group of studies was graded using a
rating system that takes into account

1.  methodological quality of the studies

2.  target population (patients with chronic kidney disease or other
    populations)

3.  study outcomes (health outcomes or surrogate measures for those
    outcomes).

(See Table 183 in the original guideline document)

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis\
Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Two types of tables were prepared using data extracted from accepted
articles. Evidence tables contain data derived from the data extraction
forms that covered features of the study design, patient demographics,
disease characteristics, interventions, definitions of the outcomes, and
their results. These detailed evidence tables, with information spanning
across several pages for each study, were made available to Work Group
members for the purpose of reviewing the data and writing of guidelines.
The evidence tables are not published along with the guidelines.

Using the information in the evidence tables, the Evidence Review Team
also prepared a set of summary tables that succinctly describe the
characteristics for each study in six areas: study size; applicability
(type of study subjects); baseline information (kidney function, level
of proteinuria, and blood pressure in comparator group one); information
on therapy in each treatment arm (antihypertensive agents or blood
pressure targets tested as well as the blood pressure at the end of the
study); results of the primary outcome (the main or composite primary
outcome and the magnitude of the effect); and methodological quality.

**Grading of Individual Studies**

*Study Size*

The number of patients (N, sample size) is used as a measure of the
weight of the evidence. In general, large studies provide more precise
estimates of effects or associations. In addition, results from large
studies are more likely to be applied to a broader population; however,
large size alone does not guarantee a high degree of applicability. A
study that enrolls a large number of selected patients may be less
generalizable than several smaller studies that include a broad spectrum
of patient populations.

*Applicability*

Applicability (also known as generalizability or external validity)
addresses the issue of whether the study sample is sufficiently broad so
that the results can be applied to the population of interest at large.
The study sample is defined by the inclusion and exclusion criteria. The
target population was defined to include patients with chronic kidney
disease (CKD) and those at increased risk of CKD, except where noted. A
designation for applicability was assigned to each article, according to
a three-level scale. In making this assessment, sociodemographic
characteristics were considered, as were the stated causes of CKD and
prior treatments. If the study is not considered broadly generalizable,
reasons for the limited applicability are reported. Table 178 in
Appendix 1 of the original guideline document describes the Work
Group\'s approach to assessing applicability.

*Results*

The type of results available in each study is determined by the study
design, the purpose, and the question(s) being asked. The Work Group
decided that the outcomes of interest were primary outcomes documenting
effects on kidney disease progression, all-cause mortality, or cardiac
outcomes in randomized controlled trials. Given the large spectrum of
different outcomes, results were collapsed into four categories: direct
health outcomes related to kidney disease progression (kidney failure,
changes in glomerular filtration rate \[GFR\], changes in serum
creatinine), surrogate outcome category related to kidney disease
progression (proteinuria), direct health outcomes related to
cardiovascular disease (CVD) (clinical events), and surrogate outcomes
related to CVD (left ventricular hypertrophy or carotid artery intima
thickness). Table 179 in Appendix 1 of the original guideline document
shows the approach in reporting comparisons of blood pressure targets or
antihypertensive agents. For studies reporting adverse effects of
angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor
blockers (ARBs), the incidence of adverse effects (i.e., drug reduction
or discontinuation for hyperkalemia, for early decrease in GFR or for
any adverse effect) were reported as percentages

*Methodological Quality*

Methodological quality (or internal validity) refers to the design,
conduct, and reporting of the clinical study. Because studies with a
variety of types of design were evaluated, a generic three-level
classification of study quality was devised (see Table 180 in appendix 1
of the original guideline document).

*Summarizing Review Articles and Selected Original Articles*

Work Group members had wide latitude in summarizing review articles.
They selected original articles for topics that were determined, a
priori, not to require a systematic review of the literature. The use of
published or derived tables and figures was encouraged to simplify the
presentation.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

**Overview of Process**

The development of these guidelines followed four basic principles set
forth by Kidney Disease Outcomes Quality Initiative (K/DOQI):

1.  The guidelines were developed using a scientifically rigorous
    process, and the rationale and evidentiary basis for each guideline
    is clearly explained.

2.  A multidisciplinary Work Group, with expertise in the management of
    chronic kidney disease (CKD), blood pressure, and cardiovascular
    disease (CVD), developed the guidelines.

3.  The Work Group members worked independently from organizational
    affiliations and had final responsibility for determining guideline
    content.

4.  The guidelines have undergone widespread critical review before they
    were finalized.

The guidelines were developed using an evidence-based approach similar
to that endorsed by the Agency for Healthcare Research and Quality.
Development of the guideline and evidence report required many
concurrent steps. The Work Group reviewed all pertinent, published
evidence, and critically appraised the quality of studies and the
overall strength of evidence supporting each recommendation.

**Refinement of Topics and Development of Materials**

The Work Group and Evidence Review Team developed (1) draft guideline
statements; (2) draft rationale statements that projected the pertinent
evidence; (3) mock summary tables providing a shell for the expected
evidence; and (4) data extraction forms prompting the reviewers for
relevant data elements to be retrieved from the primary articles. The
development process included creation of initial mock guidelines and
tables by the Work Group Chair and Evidence Review Team, followed by
iterative refinement by the Work Group members. The refinement process
began prior to literature retrieval and continued through all stages of
the project until the drafting of the final report. The refinement
occurred by e-mail, telephone, and in-person communication regularly
with local experts and with all experts during in-person meetings of the
Evidence Review Team and Work Group members. Throughout the process of
topic refinement, the type of study design that would be appropriate to
address the topics of interest was carefully considered.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grade A**

It is strongly recommended that clinicians routinely follow the
guideline for eligible patients. There is strong evidence that the
practice improves health outcomes.

**Grade B**

It is recommended that clinicians routinely follow the guideline for
eligible patients. There is moderately strong evidence that the practice
improves health outcomes.

**Grade C**

It is recommended that clinicians consider following the guideline for
eligible patients. This recommendation is based on either weak evidence
or on the opinions of the Work Group and reviewers, that the practice
might improve health outcomes.

Health outcomes are health-related events, conditions, or symptoms that
can be perceived by individuals to have an important effect on their
lives. Improving health outcomes implies that benefits outweigh any
adverse effect.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Comparison with Guidelines from Other Groups\
External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines underwent widespread critical review before they were
finalized. A list of individuals and organizations who reviewed draft
guidelines is provided in the acknowledgements section of the original
guideline document.

In addition, the guidelines were compared with other published
guidelines and recommendations on hypertension and antihypertensive
agents in chronic kidney disease (CKD), including those from the
following guidelines and groups: the Sixth and Seventh Reports of the
Joint National Committee on the Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC-6 and JNC-7); National Kidney
Foundation Task Force on Cardiovascular Disease in Chronic Renal
Disease; Department of Veterans Affairs; Veterans Health Administration;
New Zealand Guidelines Group; American Society of Transplantation;
Report of Management of Hypertension in Adults with Renal Disease and
Diabetes by the Executive Committee of the National Kidney Foundation
Councils on Hypertension and on Diabetic Kidney Disease; Scottish
Intercollegiate Guidelines Network; American Diabetes Association;
National Kidney Foundation-Kidney Disease Outcomes Quality Initiative
(NKF-K/DOQI) Clinical Practice Guidelines on CKD; Institute for Clinical
Systems Improvement; British Renal Association; Caring for Australians
with Renal Impairment (CARI) guidelines; NKF-K/DOQI Clinical Practice
Guidelines on Hypertension and Antihypertensive Agents in CKD; National
Kidney Disease Education Program, National Institute of Diabetes,
Digestive, and Kidney Disease.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*Definitions for the Recommendations Ratings (A-C) are provided at the
end of the \"Major Recommendations\" field*.

**[Guideline 1: Goals of Antihypertensive Therapy in Chronic Kidney
Disease (CKD)]{.underline}**

Hypertension is common in CKD and is a risk factor for faster
progression of kidney disease and development and worsening of
cardiovascular disease (CVD). Some antihypertensive agents also slow the
progression of kidney disease by mechanisms in addition to their
antihypertensive effect.

1.1 Antihypertensive therapy should be used in CKD to:

> 1.1.a. Lower blood pressure (**A**)
>
> 1.1.b. Reduce the risk of CVD, in patients with or without
> hypertension (**B**) (see Guideline 7)
>
> 1.1.c. Slow progression of kidney disease, in patients with or without
> hypertension (**A**) (see Guidelines 8, 9, 10)

1.2. Modifications to antihypertensive therapy should be considered
based on the level of proteinuria during treatment (**C**) (see
Guidelines 8, 9, 10, 11).

1.3. Antihypertensive therapy should be coordinated with other therapies
for CKD as part of a multi-intervention strategy (**A**).

1.4. If there is a discrepancy between the treatment recommended to slow
progression of CKD and to reduce the risk of CVD, individual
decision-making should be based on risk stratification (**C**).

**[Guideline 2: Evaluation of Patients With Chronic Kidney Disease or
Hypertension]{.underline}**

Careful initial evaluation and frequent re-evaluation are essential for
effective treatment of hypertension and use of antihypertensive agents
in CKD. Because CKD and hypertension are often present together and both
are generally asymptomatic, Guideline 2 considers evaluations of
patients with either condition.

2.1. Blood pressure should be measured at each health encounter (**A**).

2.2. Initial evaluation should include the following elements:

> 2.2.a. Description of CKD
>
> 2.2.a.i. Type (diagnosis), level of glomerular filtration rate (GFR),
> and level of proteinuria (see table below titled \"Laboratory
> Measurements for Ascertainment of CKD\") (**A**)
>
> 2.2.a.ii. Complications of decreased GFR (**A**)
>
> 2.2.a.iii. Risk for progression of kidney disease (**A**)
>
>  2.2.b. Presence of clinical CVD and CVD risk factors (see table
> below titled \"Measurements for Ascertainment of CVD and CVD Risk
> Factors in CKD) (**A**)
>
>  2.2.c. Comorbid conditions (**A**)
>
>  2.2.d. Barriers to self-management, adherence to diet and other
> lifestyle modifications, adherence to pharmacological therapy (see
> Guidelines 5, 6, and 7) (**B**)
>
>  2.2.e. Complications of pharmacological therapy (see Guidelines 7,
> 11-12) (**A**)
>
> 2.3. A clinical action plan should be developed for each patient,
> based on the stage of CKD (see table below titled \"Stages of CKD: A
> Clinical Action Plan\") (**B**).
>
> 2.4. Recommended intervals for follow-up evaluation should be guided
> by clinical conditions (see table below titled \"Recommended Interval
> for Follow-up Evaluation in CKD\") (**C**).
>
> 2.5. Patients with resistant hypertension should undergo additional
> evaluation to ascertain the cause (**B**).
>
> 2.6. Patients should be referred to specialists, when possible, for
> certain indications (see table below titled \"Recommendations for
> Referral to Specialists for Consultation and Co-Management of CKD\").
>
> **Table. Laboratory Measurements for Ascertainment of CKD**

+-----------------------------------------------------------------------+
| **For all patients at increased risk for CKD:**                       |
+-----------------------------------------------------------------------+
| -   Serum creatinine to estimate GFR                                  |
+-----------------------------------------------------------------------+
| -   Albumin-to-creatinine or protein-to-creatinine ratio in a         |
|     first-morning or random untimed \"spot\" urine specimen           |
+-----------------------------------------------------------------------+
| -   Examination of the urine sediment or dipstick for red blood cells |
|     and white blood cells                                             |
+-----------------------------------------------------------------------+
| **For patients found to have CKD:**                                   |
+-----------------------------------------------------------------------+
| -   Imaging of the kidneys, usually by ultrasound                     |
+-----------------------------------------------------------------------+
| -   Serum electrolytes (sodium, potassium, chloride, and bicarbonate) |
+-----------------------------------------------------------------------+

> **Table. Measurements for Ascertainment of CVD and CVD Risk Factors in
> CKD**

+-----------------------------------------------------------------------+
| -   12-lead electrocardiogram (EKG)                                   |
+-----------------------------------------------------------------------+
| -   Serum glucose                                                     |
+-----------------------------------------------------------------------+
| -   Fasting lipid panel                                               |
+-----------------------------------------------------------------------+
| -   Height and weight to calculate body mass index (BMI)              |
+-----------------------------------------------------------------------+

> **Table. Stages of CKG: A Clinical Action Plan**

  ------------------------------------------------------------------------------
  **Stage**   **Description**        **GFR                **Action\***
                                     (mL/min/1.73m^2^**   
  ----------- ---------------------- -------------------- ----------------------
  **1**       Kidney damage with     [\>]{.underline}90   Diagnosis and
              normal or increased                         treatment;\
              GFR                                         Treatment of comorbid
                                                          conditions;\
                                                          Slowing progression;\
                                                          CVD risk reduction

  **2**       Kidney damage with     60-89                Estimating progression
              mild decreased GFR                          

  **3**       Moderate decreased GFR 30-59                Evaluating and
                                                          treating complications

  **4**       Severe decreased GFR   15-29                Preparation for kidney
                                                          replacement therapy

  **5**       Kidney failure         \<15 (or dialysis)   Replacement (if uremia
                                                          present)
  ------------------------------------------------------------------------------

> **Notes**: CKD is defined as either kidney damage or GFR \<60
> mL/min/1.73 m^2^ for [\>]{.underline}3 months. Kidney damage is
> defined as pathologic abnormalities or markers of damage, including
> abnormalities in blood or urine tests or imaging studies.\
> \*Includes actions from preceding stages.
>
> **Table. Recommended Interval for Follow-up Evaluation in CKD**

  ----------------------------------------------------------------------------
  **Clinical Condition**     **After Initiation or    
                             Increase in Dose of      
                             Antihypertensive         
                             Therapy**                
  -------------------------- ------------------------ ------------------------
  ** **                      **4-12 weeks**           **\<4 weeks**

  Systolic blood pressure    120-139\*                [\>]{.underline}140 or
  (SBP) (mm Hg)                                       \<120

  GFR (mL/min/1.73 m^2^)     [\>]{.underline}60       \<60

  Early GFR decline (70)     \<15                     [\>]{.underline}15

  Serum potassium (meq/L0    \>4.5^a^ or              [\<]{.underline}4.5^a^
                             [\<]{.underline}4.5^b^   or \>4.5^b^

  ** **                      **After Blood Pressure   
                             is at Goal and Dose is   
                             Stable**                 

                             **6-12 months**          **1-6 months**

  GFR (mL/min/1.73 m^2^)     [\>]{.underline}60       \<60

  GFR decline mL/min/1.73    \<4 (slow)               [\>]{.underline}4 (fast)
  m^2^ per year)                                      

  Risk factors for faster    No                       Yes
  progression of CKD                                  

  Risk factors for acute GFR No                       Yes
  decline                                             

  Comorbid conditions        No                       Yes
  ----------------------------------------------------------------------------

> **Notes**: Clinicians are advised to evaluate each parameter and
> select the follow-up interval for the parameter that requires the
> earliest follow-up ^a^for thiazide or loop diuretic therapy, ^b^for
> angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor
> blocker (ARB) therapy.\
> \* 120-129 mm Hg, to monitor for hypertension; 130-139 mm Hg to reach
> blood pressure goal.
>
> **Table. Recommendations for Referral to Specialists for Consultation
> and Co-Management of CKD\*.**

  -----------------------------------------------------------------------
  **Indication**                              **Specialist**
  ------------------------------------------- ---------------------------
  Evaluation and management of CKD, as        Kidney disease specialist
  described in Kidney Disease Outcomes        (**C**); Other specialists
  Quality Initiative CKD Clinical Action Plan as appropriate (**C**)

  GFR \<30 mL/min/1.73 m^2^                   Kidney disease specialist
                                              (**B**)

  Spot urine total protein-to-creatinine      Kidney disease specialist
  ration \>500-1,000 mg/g                     (**C**)

  Increased risk for progression of kidney    Kidney disease specialist
  disease                                     (**C**)

  GFR decline \>30% within 4 months without   Kidney disease specialist
  explanation\*\*                             (**C**)

  Hyperkalemia (serum potassium concentration Kidney disease specialist
  \>5.5 mEq/L) despite treatment              (**C**)

  Resistant hypertension                      Kidney disease or
                                              hypertension specialist
                                              (**C**)

  Difficult-to-manage drug complications      Kidney disease or
                                              hypertension specialist
                                              (**C**)

  Acute presentations of CVD                  Cardiovascular disease
                                              specialist (**C**)

  Complex or severe chronic CVD conditions    Cardiovascular disease
                                              specialist (**C**)

  Age \<18 years                              Pediatric kidney disease
                                              specialist (**C**)
  -----------------------------------------------------------------------

> \* Availability of specialists may vary, depending on location.\
> \*\* Defined as \"fast\" GFR decline (\>4 mL/min/1.73 m^2^ per year)
> or risk factors for fast GFR decline. Short-term decline in GFR up to
> 30% may be seen after initiation of ACE inhibitor or ARB and does not
> require referral to specialists in the absence of other indications.\
> **Note**: Letters in parentheses indicate strength of recommendations.
>
> **[Guideline 3: Measurement of Blood Pressure in Adults]{.underline}**
>
> Blood pressure can be determined by resting blood pressure measurement
> in the health-care provider\'s office (casual blood pressure \[CBP\]),
> self-measured blood pressure (SMBP), or ambulatory blood pressure
> monitoring (ABPM).
>
> 3.1. Blood pressure should be measured according to the
> recommendations for indirect measurement of arterial blood pressure of
> the American Heart Association and Seventh Report of the Joint
> National Committee on the Prevention, Detection, Evaluation and
> Treatment of High Blood Pressure (JNC 7) (**A**).
>
> 3.2. Patients should be taught to measure and record their blood
> pressure, whenever possible (**C**).
>
> 3.3. Ambulatory blood pressure monitoring should be considered for
> patients with CKD for the following indications (**C**):
>
> 3.3.a. Suspected white coat hypertension
>
> 3.3.b. Resistant hypertension
>
> 3.3.c. Hypotensive symptoms while taking antihypertensive medications
>
> 3.3.d. Episodic hypertension
>
> 3.3.e. Autonomic dysfunction
>
> **[Guideline 4: Evaluation for Renal Artery Disease]{.underline}**
>
> Renal artery disease (RAD) is a cause of CKD and hypertension and can
> be present in patients with other causes of CKD, such as diabetes or
> hypertensive nephrosclerosis, and CKD in the kidney transplant.
>
> 4.1. For patients in whom there is a clinical suspicion of RAD, the
> clinician should do one or more of the following:
>
> 4.1.a. Estimate the probability of RAD using a predictive index
> derived from clinical characteristics (**B**)
>
> 4.1.b. Obtain a noninvasive screening test for RAD (**A**)
>
> 4.1.c. Refer to a kidney disease or hypertension specialist for
> evaluation (**C**).
>
> 4.2. Patients found to have hemodynamically significant RAD should be
> referred to a kidney disease or hypertension specialist for management
> (**C**).
>
> **[Guideline 5: Education on Self-Management Behavior]{.underline}**
>
> Antihypertensive therapy must take into consideration the patient\'s
> perception of the health-care provider\'s advice and prescriptions,
> factors that may influence self-management behaviors, and the
> likelihood that the patient will adhere to recommendations.
>
> 5.1. Self-management principles should be incorporated into the
> treatment plan (**B**).
>
> 5.2. Patient and family education about antihypertensive therapy
> should be culturally sensitive, sensitive to economic considerations,
> and based on the patient\'s level of understanding (**B**).
>
> 5.3. All patients should be assessed for barriers to adherence and
> self-management (**B**), and referred for further counseling as needed
> to a nurse practitioner, registered nurse, registered dietitian,
> masters prepared social worker, pharmacist, physician assistant, or
> other professional (**C**).
>
> **[Guideline 6: Dietary and Other Therapeutic Lifestyle Changes in
> Adults]{.underline}**
>
> Dietary and other therapeutic lifestyle modifications are recommended
> as part of a comprehensive strategy to lower blood pressure and reduce
> CVD risk in CKD.
>
> 6.1. Dietary sodium intake of less than 2.4 g/d (less than 100 mmol/d)
> should be recommended in most adults with CKD and hypertension
> (**A**).
>
> 6.2. Other dietary recommendations for adults should be modified
> according to the stage of CKD (see table below titled \"Macronutrient
> Composition and Mineral Content of the Dietary Approaches to Stop
> Hypertension \[DASH\] Recommended by JNC 7, with Modifications for
> Stages 3-4 of CKD\") (**B**).
>
> 6.3. Lifestyle modifications recommended for CVD risk reduction should
> be recommended as part of the treatment regimen (see table below
> titled \"Other Lifestyle Modifications Recommended by JNC 7\")
> (**B**).
>
> 6.4. Referral to a registered dietitian should be considered to help
> patients achieve dietary recommendations (**C**).
>
> **Table. Macronutrient Composition and Mineral Content of the Dietary
> Approaches to Stop Hypertension (DASH) Recommended by JNC 7, with
> Modifications for Stages 3-4 of CKD**

  ------------------------------------------------------------------------
  **Nutrient**                **Stage of CKD**     
  --------------------------- -------------------- -----------------------
  ** **                       **Stages 1-4**       

  Sodium (g/day)\*            \<2.4                

  Total Fat (% of calories)   \<30                 

  Saturated Fat (% of         \<10                 
  calories)                                        

  Cholesterol (mg/day)        \<200                

  Carbohydrate (% of          50-60                
  calories)\*\*                                    

  ** **                       **Stages 1-2**       **Stages 3-4**

  Protein (g/kg/day, % of     1.4 (approximately   0.6-0.8 (approximately
  calories)                   18)                  10)

  Phosphorus (g/day)          1.7                  0.8-1.0

  Potassium (g/day)           \>4                  2-4
  ------------------------------------------------------------------------

> \*Not recommended for patients with \"salt-wasting.\"\
> \*\*Adjust so total calories from protein, fat, and carbohydrate is
> 100%.
>
> **Table. Other Lifestyle Modifications Recommended by JNC 7**

  -----------------------------------------------------------------------
  **Lifestyle Component**          **Recommendation**
  -------------------------------- --------------------------------------
  Weight maintenance if BMI \<25   Balanced diet to maintain desirable
  mg/m^2^                          body weight

  Weight loss if overweight or     Calorie restricted, balanced diet
  obese (BMI [\>]{.underline} 25   
  kg/m^2^)                         

  Exercise and physical activity   Moderate intensity for 30 minutes/day,
                                   most days of week

  Moderation of alcohol intake     [\<]{.underline}2 drinks/day (men),
                                   [\<]{.underline}1 drink per day
                                   (women)

  Smoking cessation                Counseling, nicotine supplementation
  -----------------------------------------------------------------------

> **[Guideline 7: Pharmacological Therapy: Use of Antihypertensive
> Agents in CKD]{.underline}**
>
> All antihypertensive agents can be used to lower blood pressure in
> CKD. Multi-drug regimens will be necessary in most patients with CKD
> to achieve therapeutic goals. Patients with specific causes of kidney
> disease and CVD will benefit from specific classes of agents.
>
> 7.1. Patients with CKD should be considered in the \"highest-risk\"
> group for CVD for implementing recommendations for pharmacological
> therapy, irrespective of cause of CKD (**A**).
>
> 7.2. Target blood pressure for CVD risk reduction in CKD should be
> \<130/80 mm Hg (**B**).
>
> 7.3. Antihypertensive agents should be prescribed as follows, when
> possible:
>
> 7.3.a. Preferred agents for CKD should be used first (see Guidelines
> 8, 9, 10, 11) (**A**).
>
> 7.3.b. Diuretics should be included in the antihypertensive regimen in
> most patients (**A**).
>
> 7.3.c. Choose additional agents based on cardiovascular
> disease-specific indications to achieve therapeutic and preventive
> targets (see table below titled \"Preferred Antihypertensive Agents
> for CVD\") and to avoid side-effects and interactions (**B**).
>
> 7.4. The antihypertensive regimen should be simplified as much as
> possible (**B**).
>
> 7.4.a. Long-acting (once-daily agents) should be used when possible
> (**B**).
>
> 7.4.b. Two agents, either as separate prescriptions or as a fixed-dose
> combination containing preferred agents, may be considered as initial
> therapy for systolic blood pressure (SBP) \>20 mm Hg above goal
> according to the stage of CKD and CVD risk (**C**).
>
> 7.4.c. Fixed-dose combinations may be used for maintenance therapy
> after the antihypertensive regimen has been established (**B**).
>
> **Table. Preferred Antihypertensive Agents for CVD**

  -----------------------------------------------------------------------------------------------------
  **Types of CVD**   **Thiazide or **ACE        **Beta-Blockers**   **Calcium-Channel   **Aldosterone
                     Loop          Inhibitors                       Blockers**          Antagonists**
                     Diuretics**   or ARBs**                                            
  ------------------ ------------- ------------ ------------------- ------------------- ---------------
  Heart Failure with X             X            X^a^                                    X
  Systolic                                                                              
  Dysfunction                                                                           

  Post Myocardial                  X            X                                       X
  Infarction (MI)                                                                       
  with Systolic                                                                         
  Dysfunction                                                                           

  Post MI                                       X                                        

  Chronic Stable                                X                   X                    
  Angina                                                                                

  High-Risk for      X             X            X                   X                    
  Coronary Artery                                                                       
  Disease                                                                               

  Recurrent Stroke   X             X                                                     
  Prevention                                                                            

  Supraventricular                              X                   X^b^                 
  Tachycardia                                                                           
  -----------------------------------------------------------------------------------------------------

> ^a^ Only some beta-blockers (carvedilol, bisoprolol, metoprolol
> succinate)\
> ^b^ Nondihydropyridine calcium-channel blockers
>
> **[Guideline 8: Pharmacological Therapy: Diabetic Kidney
> Disease]{.underline}**
>
> Diabetes mellitus is the most common cause of kidney failure in the
> United States. Diabetic kidney disease is characterized by the early
> onset of albuminuria, hypertension, and a high risk of coexistent or
> subsequent CVD.
>
> 8.1. Target blood pressure in diabetic kidney disease should be
> \<130/80 mm Hg (Guideline 7) (see table below titled \"Hypertension
> and Antihypertensive Agents in Diabetic Kidney Disease\").
>
> 8.2. Patients with diabetic kidney disease, with or without
> hypertension, should be treated with an ACE inhibitor or an ARB (see
> table below titled \"Hypertension and Antihypertensive Agents in
> Diabetic Kidney Disease \").
>
> **Table. Hypertension and Antihypertensive Agents in Diabetic Kidney
> Disease**

  --------------------------------------------------------------------------------
  **Clinical Assessment**  **Target      **Preferred    **Other Agents to Reduce
                           Blood         Agents for     CVD Risk and Reach Target
                           Pressure**    CKD**          Blood Pressure**
  ------------------------ ------------- -------------- --------------------------
  Blood pressure           \<130/80 mm   ACE inhibitor  Diuretic preferred, then
  [\>]{.underline}130/80   Hg **(B)**    or ARB **(A)** beta-blocker or
  mm Hg                                                 calcium-channel blocker
                                                        **(A)**

  Blood pressure \<130/80                ACE inhibitor   
  mm Hg                                  or ARB **(A)** 
  --------------------------------------------------------------------------------

> **Note**: Letters in parentheses denote strength of recommendations.
>
> **[Guideline 9: Pharmacological Therapy: Nondiabetic Kidney
> Disease]{.underline}**
>
> Nondiabetic kidney diseases include glomerular diseases other than
> diabetes, vascular diseases other than renal artery disease,
> tubulointerstitial diseases, and cystic disease. Among these diseases,
> the level of proteinuria is useful for diagnosis and prognosis.
> Glomerular diseases are characterized by higher levels of proteinuria
> than other diseases. Higher levels of proteinuria are associated with
> faster progression of kidney disease and increased risk of CVD.
>
> 9.1. Target blood pressure in nondiabetic kidney disease should be
> \<130/80 mm Hg (Guideline 1) (see table below titled \"Hypertension
> and Antihypertensive Agents in Nondiabetic Kidney Disease\").
>
> 9.2. Patients with nondiabetic kidney disease and spot urine total
> protein to creatinine ratio [\>]{.underline}200 mg/g, with or without
> hypertension, should be treated with an ACE inhibitor or ARB (see
> table below titled \"Hypertension and Antihypertensive Agents in
> Nondiabetic Kidney Disease\").
>
> **Table. Hypertension and Antihypertensive Agents in Nondiabetic
> Kidney Disease**

  --------------------------------------------------------------------------
  **Clinical Assessment**  **Target     **Preferred   **Additional Agents to
                           Blood        Agents for    Reduce CVD Risk and
                           Pressure**   CKD**         Reach Target Blood
                                                      Pressure**
  ------------------------ ------------ ------------- ----------------------
  Blood pressure           \<130/80 mm  ACE inhibitor Diuretic preferred,
  [\>]{.underline}130/80   Hg **(A)**   or ARB        then beta-blocker or
  mm Hg and spot urine                  **(A)**       calcium-channel
  total                                               blocker **(A)**
  protein-to-creatinine                               
  ratio                                               
  [\>]{.underline}200 mg/g                            

  Blood pressure           \<130/80 mm  None          Diuretic preferred,
  [\>]{.underline}130/80   Hg **(B)**   preferred     then ACE inhibitor,
  mm Hg and spot urine                                ARB, beta-blocker or
  total                                               calcium-channel
  protein-to-creatinine                               blocker **(A)**
  ratio \<200 mg/g                                    

  Blood pressure \<130/80               ACE inhibitor Diuretic preferred,
  mm Hg and spot urine                  or ARB        then beta-blocker or
  total                                 **(C)**       calcium-channel
  protein-to-creatinine                               blocker **(A)**
  ratio                                               
  [\>]{.underline}200 mg/g                            

  Blood pressure \<130/80               None           
  mm Hg and spot urine                  preferred     
  total                                               
  protein-to-creatinine                               
  ratio \<200 mg/g                                    
  --------------------------------------------------------------------------

> **Note**: Letters in parentheses denote strength of recommendations.
>
> **[Guideline 10: Pharmacological Therapy: Kidney Disease in the Kidney
> Transplant Recipient]{.underline}**
>
> Most kidney transplant recipients have CKD and hypertension. High
> blood pressure in kidney transplant recipients is a risk factor for
> faster progression of CKD and development of CVD.
>
> 10.1. The target blood pressure in kidney transplant recipients should
> be \<130/80 mm Hg (see Guideline 7) (see table below titled
> \"Hypertension and Antihypertensive Agents in Kidney Disease in the
> Kidney Transplant Recipient\").
>
> 10.2. Patients with CKD in the kidney transplant should be treated
> with any of the following to reach the target blood pressure: calcium
> channel blocker (CCB), diuretics, ACE inhibitor, ARB, or beta-blocker
> (see table below titled \"Hypertension and Antihypertensive Agents in
> Kidney Disease in the Kidney Transplant Recipient\").
>
> **Table. Hypertension and Antihypertensive Agents in Kidney Disease in
> the Kidney Transplant Recipient**

  --------------------------------------------------------------------------------
  **Clinical Assessment**  **Target     **Preferred    **Additional Agents to
                           Blood        Agents for     Reduce CVD Risk and Reach
                           Pressure**   CKD**          Target Blood Pressure**
  ------------------------ ------------ -------------- ---------------------------
  Blood pressure           \<130/80 mm  None preferred CCB, diuretics, ACE
  [\>]{.underline}130/80   Hg **(B)**                  inhibitor, ARB,
  mm Hg                                                beta-blocker **(B)**

  Blood pressure \<130/80               None preferred  
  mm Hg                                                
  --------------------------------------------------------------------------------

> **Note**: Letters in parentheses denote strength of recommendations.
>
> **[Guideline 11: Use of Angiotensin-Converting Enzyme Inhibitors and
> Angiotensin Receptor Blockers in CKD]{.underline}**
>
> ACE inhibitors and ARBs can be used safely in most patients with CKD.
>
> 11.1. ACE inhibitors and ARBs should be used at moderate to high
> doses, as used in clinical trials (**A**).
>
> 11.2. ACE inhibitors and ARBs should be used as alternatives to each
> other, if the preferred class cannot be used (**B**).
>
> 11.3. ACE inhibitors and ARBs can be used in combination to lower
> blood pressure or reduce proteinuria (**C**).
>
> 11.4. Patients treated with ACE inhibitors or ARBs should be monitored
> for hypotension, decreased GFR, and hyperkalemia (**A**).
>
> 11.5. The interval for monitoring blood pressure, GFR, and serum
> potassium depends on baseline levels (see table below titled
> \"Recommended Intervals for Monitoring Blood Pressure, GFR, and Serum
> Potassium for Side Effects of ACE Inhibitors or ARBs in CKD\")
> (**B**).
>
> 11.6. In most patients, the ACE inhibitor or ARB can be continued if:
>
> 11.6.a. GFR decline over four months is \<30% from baseline value
> (**B**).
>
> 11.6.b. Serum potassium is \<5.5 mEq/L (**B**).
>
> 11.7 ACE inhibitors and ARBs should not be used or used with caution
> in certain circumstances (see table below titled \"Circumstances in
> which ACE Inhibitors and ARBs Should Not Be Used\").
>
> **Table. Recommended Intervals for Monitoring Blood Pressure, GFR, and
> Serum Potassium for Side Effects of ACE Inhibitors or ARBs in CKD**

  -------------- ---------------------------------------- ----------------------- ---------------------
  **Baseline     **SBP (mm Hg)**                          [\>]{.underline}120\*   \<120
  Value**                                                                         

                 **GFR (mL/min/1.73 m^2^)**               [\>]{.underline}60      \<60

                 **Early GFR Decline (%)**                \<15                    [\>]{.underline}15

                 **Serum Potassium (mEg/L)**              [\<]{.underline}4.5     [\>]{.underline}4.5

  **Interval**   **After Initiation or Increase in Dose   4-12 weeks              [\<]{.underline}4
                 of ACE inhibitor or ARB**                                        weeks

                 **After Blood Pressure is at Goal and    6-12 weeks              1-6 months
                 Dose is Stable**                                                 
  -------------- ---------------------------------------- ----------------------- ---------------------

> \*See Guideline 7 for recommended intervals to reach blood pressure
> goal.
>
> **Table. Circumstances in which ACE Inhibitors and ARBs Should Not Be
> Used**

  -------------------------------------------------------------------------
  ** **         **Do Not Use**              **Use with Caution**
  ------------- --------------------------- -------------------------------
  **ACE         Pregnancy **(A)**\          Women not practicing
  Inhibitor**   History of angioedema       contraception **(A)**\
                **(A)**\                    Bilateral renal artery
                Cough due to ACE inhibitors stenosis\***(A)**\
                **(A)**\                    Drugs causing hyperkalemia
                Allergy to ACE inhibitor or **(A)**
                ARB **(A)**                 

  **ARB**       Allergy to ACE inhibitor or Bilateral renal artery
                ARB **(A)**\                stenosis\***(A)**\
                Pregnancy **(C)**\          Drugs causing hyperkalemia
                Cough due to ARB **(C)**    **(A)**\
                                            Women not practicing
                                            contraception **(C)**\
                                            Angioedema due to ACE
                                            inhibitors **(C)**
  -------------------------------------------------------------------------

> \*Including renal artery stenosis in the kidney transplant or in a
> solitary kidney.\
> **Note**: Letters in parentheses denote strength of recommendations.
>
> **[Guideline 12: Use of Diuretics in CKD]{.underline}**
>
> Diuretics are useful in the management of most patients with CKD. They
> reduce extracellular fluid (ECF) volume; lower blood pressure;
> potentiate the effects of ACE inhibitors, ARBs, and other
> antihypertensive agents; and reduce the risk of CVD in CKD. Choice of
> diuretic agents depends on the level of GFR and need for reduction in
> ECF volume.
>
> 12.1. Most patients with CKD should be treated with a diuretic
> (**A**).
>
> 12.1.a. Thiazide diuretics given once daily are recommended in
> patients with GFR [\>]{.underline}30 mL/min/1.73 m^2^ (CKD Stages 1-3)
> (**A**).
>
> 12.1.b. Loop diuretics given once or twice daily are recommended in
> patients with GFR \<30 mL/min/1.73 m^2^ (CKD Stages 4-5) (**A**).
>
> 12.1.c. Loop diuretics given once or twice daily, in combination with
> thiazide diuretics, can be used for patients with ECF volume expansion
> and edema (**A**).
>
> 12.1.d. Potassium-sparing diuretics should be used with caution:
>
> 12.1.d.i. In patients with GFR \<30 mL/min/1.73 m^2^ (CKD Stages 4-5)
> (**A**)
>
> 12.1.d.ii. In patients receiving concomitant therapy with ACE
> inhibitors or ARBs (**A**)
>
> 12.1.d.iii. In patients with additional risk factors for hyperkalemia
> (**A**)
>
> 12.2. Patients treated with diuretics should be monitored for:
>
> 12.2.a. Volume depletion, manifest by hypotension or decreased GFR
> (**A**)
>
> 12.2.b. Hypokalemia and other electrolyte abnormalities (**A**)
>
> 12.2.c. The interval for monitoring depends on baseline values for
> blood pressure, GFR, and serum potassium concentration (see table
> below titled \"Recommended Intervals for Monitoring Blood Pressure,
> GFR, and Serum Potassium for Side Effects of Diuretics in CKD\")
> (**B**).
>
> 12.3. Long-acting diuretics and combinations of diuretics with other
> antihypertensive agents should be considered to increase patient
> adherence (**B**).
>
> **Table. Recommended Intervals for Monitoring Blood Pressure, GFR, and
> Serum Potassium for Side Effects of ACE Diuretics in CKD**

  -------------- ----------------------------------------- ----------------------- ---------------------
  **Baseline     **Baseline SBP (mm Hg)**                  [\>]{.underline}120\*   \<120
  Value**                                                                          

                 **Baseline GFR (mL/min/1.73 m^2^)**       [\>]{.underline}60      \<60

                 **Early GFR Decline (%)**                 \<15                    [\>]{.underline}15

                 **Baseline Serum Potassium (mEg/L) for    \>4.5                   [\<]{.underline}4.5
                 Thiazide and Loop Diuretics**                                     

                 **Baseline Serum Potassium (mEg/L) for    [\<]{.underline}4.0     \>4.0
                 Potassium-Sparing Diuretics**                                     

  **Interval**   **After Initiation or Increase in Dose**  4-12 weeks              [\<]{.underline}4
                                                                                   weeks

                 **After Blood Pressure is at Goal and     6-12 weeks              1-6 months
                 Dose is Stable**                                                  
  -------------- ----------------------------------------- ----------------------- ---------------------

> \*See Guideline 7 for recommended intervals to reach blood pressure
> goal.
>
> **[Guideline 13: Special Considerations in Children]{.underline}**
>
> Hypertension is common in children with CKD. Because of their young
> age at onset of CKD and hypertension, children have a high lifetime
> exposure to risk factors for CVD. Thus, children with CKD are at high
> risk of complications from hypertension.
>
> 13.1. Measurement of blood pressure in children should be performed
> with age- and size-appropriate equipment, and blood pressure values
> should be interpreted according to normal values adjusted for age,
> gender, and height percentile, as recommended by the 1996 Update on
> the Task Force Report on High Blood Pressure in Children and
> Adolescents: A Working Group Report from the National High Blood
> Pressure Education Program (**A**).
>
> 13.2. The cause of CKD and age of the child should be considered in
> selecting the class of antihypertensive agent (**A**).
>
> 13.3. Target blood pressure in children should be lower than the 90th
> percentile for normal values adjusted for age, gender, and height or
> 130/80 mm Hg, whichever is lower (**B**).
>
> 13.4. Because of the specialized nature of CKD and blood pressure
> management in children, a pediatric kidney disease specialist should
> be involved in their care, when possible (**C**).
>
> **[Definitions]{.underline}**:
>
> **Recommendations Rating Scheme**
>
> **Grade A**
>
> It is strongly recommended that clinicians routinely follow the
> guideline for eligible patients. There is strong evidence that the
> practice improves health outcomes.
>
> **Grade B**
>
> It is recommended that clinicians routinely follow the guideline for
> eligible patients. There is moderately strong evidence that the
> practice improves health outcomes.
>
> **Grade C**
>
> It is recommended that clinicians consider following the guideline for
> eligible patients. This recommendation is based on either weak
> evidence or on the opinions of the Work Group and reviewers, that the
> practice might improve health outcomes.
>
> Health outcomes are health-related events, conditions, or symptoms
> that can be perceived by individuals to have an important effect on
> their lives. Improving health outcomes implies that benefits outweigh
> any adverse effect.

#### CLINICAL ALGORITHM(S)

> The following algorithms are provided in the original guideline:

-   General approach to hypertension and use of antihypertensive agents
    in chronic kidney disease (CKD) (see Figure 28 in the original
    guideline document)

-   Evaluation for proteinuria for evaluation of hypertension and use of
    antihypertensive agents in CKD (see Figure 30 in the original
    guideline document)

-   Evaluation of patients with CKD for treatment of hypertension and
    use of antihypertensive agents (see Figure 31 in the original
    guideline document)

-   Hypertension and antihypertensive agents in CKD (see Figure 34 in
    the original guideline document)

-   Hypertension and antihypertensive agents in diabetic kidney disease
    (see Figure 43 in the original guideline document)

-   Hypertension and antihypertensive agents in nondiabetic kidney
    disease (see Figure 51 in the original guideline document)

-   Hypertension and antihypertensive agents in kidney transplant
    recipients (see Figure 53 in the original guideline document)

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

> The recommendations were based primarily on a comprehensive review of
> published reports. In cases where the data did not appear conclusive,
> recommendations were based on the consensus opinion of the group.
>
> The rationale for each of the 13 guidelines contains a section on the
> strength of the evidence. The strength of the evidence includes a
> series of specific \"rationale statements,\" each supported by
> evidence, and \"summary tables\" (if appropriate) compiling and
> evaluating original reports of studies.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

> **Overall Potential Benefits**

-   Evaluation of patients with chronic kidney disease (CKD) or
    hypertension can help define prognosis and guide treatment.

-   The goals of antihypertensive therapy in CKD are to lower blood
    pressure, slow progression of kidney disease, and reduce risk of
    cardiovascular disease (CVD).

-   Self-management is a theory-based approach to health care that
    recognizes the central role played by the patient in health
    promotion, disease prevention, and successful management of illness.

> **Specific Potential Benefits**

-   Angiotensin-converting enzyme (ACE) inhibitors and
    angiotensin-receptor blockers (ARBs) slow the progression of
    diabetic kidney disease and nondiabetic kidney disease with
    proteinuria, and in addition, they reduce proteinuria, irrespective
    of the type of kidney disease.

-   Diuretics are useful in the management of most patients with CKD.
    They reduce extracellular fluid (ECF) volume, lower blood pressure,
    potentiate the effects of ACE inhibitors, ARBs, and other
    antihypertensive agents and reduce the risk of CVD in CKD.

-   Refer to the original guideline document for specific potential
    benefits on individual agents.

#### POTENTIAL HARMS

> **Side Effects of Medication**

-   *Peripheral alpha-adrenergic blockers*. Side effects include
    postural hypotension, diarrhea, decrease in clearance of verapamil
    (prazosin only), nasal congestion (reserpine only), sedation
    (reserpine only, incontinence priapism).

-   *Central alpha-adrenergic agonists*. Side effects include sedation,
    dry mouth, bradycardia, withdrawal hypertension, concomitant
    beta-blocker therapy), increase serum lithium levels (methyldopa
    only), hepatic and autoimmune disorders (methyldopa).

-   *Directly acting vasodilators*. Side effects include headaches,
    fluid retention, tachycardia, lupus-like syndrome (hydralazine),
    hirsutism and pericardial effusion (minoxidil only).

-   *Non-selective aldosterone antagonists (spironolactone)*: Side
    effects include hyperkalemia, metabolic acidosis, gynecomastia,
    impotence, and hypermenorrhea.

-   *Selective aldosterone antagonists (eplerenone)*. Side effects
    include hyperkalemia, metabolic acidosis, hypertriglyceridemia.

-   *Thiazide and loop diuretics*. Side effects include extracellular
    fluid (ECF) volume depletion, increase in cholesterol, increase in
    glucose, increase in uric acid, increase in calcium (not with loop
    diuretics), increase in lithium, decrease in potassium, decrease in
    sodium, decrease in magnesium; rarely causes blood dyscrasias,
    photosensitivity, pancreatitis, hyponatremia, erectile dysfunction.

-   *Potassium-sparing diuretics*. Side effects include hyperkalemia,
    metabolic acidosis, folate deficiency (triamterene), and kidney
    stones (triamterene).

-   *Non-selective beta-blockers (and high-dose selective
    beta-blockers*. Side effects include bronchospasm, impairment of
    peripheral circulation, and hyperkalemia.

-   *Lipid-soluble (metabolized in the liver) beta-blockers*. Side
    effects include impotence, fatigue, decreased exercise tolerance,
    and insomnia.

-   *All beta-blockers*. Side effects include bradycardia, masking of
    and prolonging of insulin-induced hypoglycemia, and hyperkalemia.

-   *Combined alpha and beta-blockers*. Side effects include postural
    hypotension and bronchospasm.

-   *Angiotensin-converting enzyme (ACE) inhibitors*. Side effects
    include cough, angioedema (very rare) hyperkalemia, rash, loss of
    taste, leucopenia, increase in lithium levels.

-   *Angiotensin receptor blockers*. Side effects include cough,
    angioedema (very rare), hyperkalemia, increase in lithium levels.

-   *Dihydropyridine calcium-channel blockers*. Side effects include
    edema of the ankle, flushing, headache, increase in cyclosporine
    levels (nicardipine only), gingival hypertrophy, \"dose dumping\"
    (nifedipine, nisoldipine, felodipine).

-   *Non-dihydropyridine calcium channel blockers (CCBs) (e.g.,
    diltiazem, mibefradil, verapamil)*. Side effects include the
    following: Nausea, headache (diltiazem); constipation (verapamil);
    conduction defects; worsening of systolic dysfunction; increased
    levels of other drugs metabolized by the same hepatic enzyme system;
    decreased serum lithium levels (verapamil only); increase in
    cyclosporine levels; gingival hyperplasia, constipation.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   *Angiotensin-converting enzyme (ACE) inhibitor*. Do not use in
    pregnancy, history of angioedema, cough due to ACE inhibitors,
    allergy to ACE or angiotensin receptor blocker (ARB). Use with
    caution in women not practicing contraception, individuals with
    bilateral renal artery stenosis, or with drugs causing hyperkalemia.

-   *Angiotensin Receptor Blocker*. Do not use in allergy to ACE
    inhibitor or ARB, pregnancy, cough due to ARB. Use with caution in
    bilateral renal artery stenosis, drugs causing hyperkalemia, women
    not practicing contraception, angioedema due to ACE inhibitors.

-   *Thiazide and loop diuretics*. Avoid with gout.

-   *Potassium-sparing diuretics*. Use with caution in chronic kidney
    disease (CKD) Stages 3-4 and in patients at increased risk for
    hyperkalemia.

-   *Non-selective beta-blockers (and high-dose selective
    beta-blockers*. Avoid with asthma, chronic obstructive pulmonary
    disease, and with severe peripheral vascular disease

-   *Lipid-soluble beta-blockers*. Avoid with depression and liver
    disease (labetalol only).

-   *All beta-blockers*. Avoid with bradycardia, second or third degree
    heart block, and heart failure (except carvedilol, extended release
    metoprolol, and bisoprolol).

-   *Non-dihydropyridine calcium-channel blockers (CCBs)*. Avoid with
    second and third degree heart block, congestive heart failure due to
    systolic dysfunction

-   *Peripheral alpha-adrenergic system*. Avoid with depression
    (reserpine only) and peptic ulcer disease (reserpine only)

-   *Central alpha-adrenergic blockers*. Avoid with depression and liver
    disease (methyldopa only).

-   *Directly acting vasodilators*. Avoid in lupus (hydralazine only)

-   *Non-selective (spironolactone)*. Use with caution in CKD Stages 3-4
    and in patients at increased risk for hyperkalemia

-   *Selective (eplerenone)*. Use with caution in CKD Stages 3-4 and in
    patients with increased risk of hyperkalemia

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

> **Use of the Guidelines**
>
> These guidelines are based upon the best information available at the
> time of publication. They are designed to provide information and
> assist decision-making. They are not intended to define a standard of
> care and should not be construed as one. Neither should they be
> interpreted as prescribing an exclusive course of management.
> Individual judgment by responsible clinicians is paramount in
> treatment of chronic kidney disease.
>
> Variations in practice will inevitably and appropriately occur when
> clinicians take into account the needs of individual patients,
> available resources, and limitations unique to an institution or type
> of practice. Every health-care professional making use of these
> guidelines is responsible for evaluating the appropriateness of
> applying them in the setting of any particular clinical situation.
>
> **Guideline 2: Evaluation of the Patient with Chronic Kidney Disease
> (CKD)**
>
> The risks of hypertension and the need for prompt recognition and
> evaluation in the general population are well documented. Far less
> evidence specific to the CKD population is available, and it must be
> acknowledged that many of the major hypertension trials upon which
> Joint National Committee on the Prevention, Detection, Evaluation, and
> Treatment of High Blood Pressure (JNC) guidelines are based
> specifically excluded patients with kidney disease. Nevertheless, the
> casual blood pressure (CBD) and CKD progression risks are well
> documented, and so it seems prudent to the guideline developers to
> follow accepted recommendations in this patient population.
>
> **Guideline 3: Measurement of Blood Pressure in Adults**
>
> Ambulatory blood pressure monitoring (ABPM) is becoming more widely
> used, yet important limitations remain such as the expense of
> equipment and software, and personnel required to apply the equipment;
> high test-retest variability in some individuals, and reimbursement
> issues.
>
> **Guideline 4: Evaluation for Renal Artery Disease**
>
> Recommendations for the optimal management of patients with renal
> artery disease (RAD) are limited by the absence of long-term,
> randomized trials comparing medical management versus
> revascularization interventions upon blood pressure control,
> glomerular filtration rate (GFR), and cardiovascular morbidity and
> mortality. Similarly, the absence of long-term, randomized trials of
> the medical management of RAD comparing therapy with or without
> angiotensin-converting enzyme (ACE) inhibitors and
> angiotensin-receptor blockers (ARBs) precludes recommending ACE
> inhibitors or ARBs as preferred antihypertensive agents in RAD.
>
> **Guideline 5: Education on Self-Management**
>
> Research that pertains to CKD and hypertension is limited. However,
> data obtained from other clinical populations can be extrapolated for
> use with the CKD population. Much research has been done in other
> clinical populations related to lifestyle modifications and behavioral
> factors that are implicated in an individual\'s management of
> hypertension.
>
> **Guideline 6: Dietary and Other Therapeutic Lifestyle Changes in
> Adults**
>
> There are few controlled trials designed to determine the
> effectiveness and safety of dietary therapies to lower blood pressure
> in patients with CKD.
>
> **Guideline 7: Pharmacological Therapy: Use of Antihypertensive Agents
> in CKD**
>
> There are few studies on the treatment of hypertension in CKD. Most of
> the largest clinical studies in patients with CKD were designed to
> evaluate the efficacy of therapy in slowing the progression of CKD
> rather than reducing risk of CVD. Therefore, most of the
> recommendations in Guideline 7 are extrapolated from clinical studies
> performed in the general population.
>
> **Guideline 8: Pharmacological Therapy: Diabetic Kidney Disease**
>
> Recommendations regarding pharmacological therapy in diabetic kidney
> disease need to be qualified based upon the available data. First, no
> claims of superiority between ACE inhibitors and ARBs can be made
> since no randomized trials have compared these agents \"head-to-head\"
> in slowing the progression of kidney disease. Second, efficacy of
> therapy in many studies of diabetic kidney disease with
> microalbuminuria, efficacy of antihypertensive agents was based on
> reduced risk of kidney disease progression, as assessed by development
> of microalbuminuria, rather than decline in glomerular filtration rate
> (GFR) or onset of kidney failure. It is not practical, however, to
> conduct studies for the duration of follow-up required to observe a
> reduction in GFR decline or onset of kidney failure in patients with
> microalbuminuria; this would take more than 20 years of follow-up.
> Consequently, evidence from such studies was graded \"strong.\"
> Moreover, since the level of albumin excretion in normotensive
> patients with diabetic kidney disease generally does not exceed
> \"microalbuminuria,\" the recommendation for treating patients without
> hypertension is graded as \"A.\"
>
> **Guideline 9: Pharmacological Therapy: Nondiabetic Kidney Disease**
>
> One of the challenges in creating guidelines for pharmacological
> therapy in nondiabetic kidney disease is that nondiabetic kidney
> disease encompasses a diverse array of diseases. Differentiating the
> type of nondiabetic kidney disease is another challenge. As described
> in the original guideline document, the urine sediment, and kidney
> imaging procedures may be useful. However, there is large variation in
> urine protein excretion in types of kidney disease. Therefore, urine
> protein cut-off values to suggest types of nondiabetic kidney disease
> are not precise, and urine sediment examination and kidney imaging may
> not be diagnostic. Another limitation in approaching nondiabetic
> kidney disease is that there are few large studies of a single type of
> nondiabetic kidney disease. Further modifications of these
> recommendations will require the development of more discriminating
> diagnostic techniques and large studies focusing on single types of
> nondiabetic CKD.
>
> **Guideline 10: Pharmacological Therapy: Kidney Disease in the Kidney
> Transplant Recipient**
>
> There are few randomized, controlled studies of the treatment of
> hypertension in kidney transplant recipients. Although it is clear
> from the data that dihydropyridine calcium-channel blockers are
> effective in controlling blood pressure and maintaining GFR in the
> posttransplant setting, long-term data are lacking on their
> effectiveness in slowing progression of kidney disease.
>
> **Guideline 11: Use of ACE Inhibitors and ARBs in CKD**
>
> Compared to the wealth of data on antihypertensive agents in the
> general population, there are few data that examine the use of
> antihypertensive agents in CKD, and fewer data on the adverse effects
> of those agents. Many of the randomized trials do not provide adequate
> definitions of the key adverse effects, such as hypotension, decreased
> kidney function, and hyperkalemia. Data concerning the allergic
> reactions and fetal abnormalities are derived primarily from
> observational studies. There are few comparative data either within
> groups of ACE inhibitors or ARBs, or among agents from different
> classes. It is unclear whether substitution of one agent from a
> different class will attenuate an adverse effect. Risk factors for
> adverse effects need clarification.
>
> **Guideline 12: Use of Diuretics in CKD**
>
> There is limited information from controlled trials to guide diuretic
> dosing for blood pressure control. In addition, there are very limited
> data concerning the antiproteinuric effects of diuretics and the
> combination of diuretics and ACE inhibitors or ARBs. Moreover, the
> role of diuretic therapy in CKD progression when congestive heart
> failure coexists needs to be better clarified.
>
> **Guideline 13: Special Considerations in Children**
>
> There are virtually no studies in children that evaluate the effect of
> antihypertensive therapy on progression of CKD or the incidence of
> cardiovascular disease. Multiple studies demonstrate that
> antihypertensive therapy is effective in lowering blood pressure in
> children and some studies demonstrate that antihypertensive therapy
> with an ACE inhibitor is effective in reducing proteinuria. Thus, the
> recommendations in this guideline are based upon studies in adults and
> studies in children using surrogate markers.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

> Implementation issues related to each of the guidelines are discussed
> in the original guideline document. In addition, recommendations for
> clinical performance measures are provided for guidelines 2, 7, 8, 9,
> and 13.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

> Living with Illness

#### IOM DOMAIN

> Effectiveness\
> Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

> K/DOQI clinical practice guidelines on hypertension and
> antihypertensive agents in chronic kidney disease. Am J Kidney
> Dis 2004 May;43(5 Suppl 1):S1-290. \[625 references\]
> [PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15114537)

#### ADAPTATION

> Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

> 2004 May

#### GUIDELINE DEVELOPER(S)

> National Kidney Foundation - Disease Specific Society

#### SOURCE(S) OF FUNDING

> National Kidney Foundation (NKF)

#### GUIDELINE COMMITTEE

> NKF-K/DOQI (National Kidney Foundation-Kidney Disease Outcomes Quality
> Initiative) Hypertension and Antihypertensive Agents in Chronic Kidney
> Disease Work Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

> *Members*: Andrew S. Levey, MD (*Chair*), Tufts-New England Medical
> Center, Boston, MA; Michael V. Rocco, MD, MS (*Vice-Chair*), Wake
> Forest University School of Medicine, Winston Salem, NC; Sharon
> Anderson, MD, Oregon Health and Science University, Portland, OR;
> Sharon P. Andreoli, MD, Wells Research Center, Indiana University
> Medical Center, Indianapolis, IN; George R. Bailie, PharmD, PhD,
> Albany College of Pharmacy, Albany, NY; George L. Bakris, MD, Rush
> Presbyterian St. Luke\'s Medical Center, Chicago, IL; Mary Beth
> Callahan, ACSW, LMSW, ACP, Dallas Transplant Institute, Dallas, TX;
> Jane H. Greene, RD, CSR, Vanderbilt University, Nashville, TN; Cynda
> Ann Johnson, MD, MBA, Brody School of Medicine, East Carolina
> University, Greenville, NC; James P. Lash, MD, University of Illinois,
> Chicago, IL; Peter A. McCullough, MD, MPH, William Beaumont Hospital,
> Beaumont Health Center, Royal Oaks, MI; Edgar R. Miller III, MD, PhD,
> Johns Hopkins Medical Institutions, Baltimore, MD; Joseph V. Nally,
> MD, Cleveland Clinic Foundation, Cleveland, OH; John D. Pirsch, MD,
> University of Wisconsin Hospital & Clinic, Madison, WI; Ronald J.
> Portman, MD, University of Texas, Houston, TX; Mary Ann Sevick, RN,
> ScD, Department of Health & Community Systems, School of Nursing,
> University of Pittsburgh, Pittsburgh, PA; Domenic Sica, MD, Virginia
> Commonwealth University Health Systems, Richmond, VA; Donald E.
> Wesson, MD, Texas Tech University Health Science Center, Lubbock, TX
>
> *Liaison Members*: Lawrence Agodoa, MD, National Institutes of Health,
> NIDDK, Silver Springs, MD; Jeffrey A. Cutler, MD, MPH, National
> Institutes of Health, NHLBI, Bethesda, MD; Kline Bolton, MD (RPA),
> University of Virginia Hospital, Charlottesville, VA; Tom Hostetter,
> MD, National Institutes of Health, NIDDK, Bethesda, MD
>
> *Evidence Review Team Members*: (Tufts-New England Medical Center,
> Boston MA); Joseph Lau, MD, Director, Katrin Uhlig, MD, Assistant
> Director; Priscilla Chew, MPH; Annamaria Kausz, MD, MS; Bruce
> Kupelnick, BA; Gowri Raman, MD; Mark Sarnak, MD; Chenchen Wang, MD,
> MSc; and Brad C. Astor, PhD, MPH, Johns Hopkins University, Baltimore,
> MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

> The National Kidney Foundation makes every effort to avoid any actual
> or potential conflicts of interest that may arise as a result of an
> outside relationship or a personal, professional, or business interest
> of a member of the Work Group.
>
> Specifically, all members of the Work Group are required to complete,
> submit, and sign a Disclosure Questionnaire showing all such
> relationships that might be perceived as real or potential conflicts
> of interest. All affiliations are published in their entirety at the
> end of the original guideline document in the biographical sketches of
> the Work Group members.

#### GUIDELINE STATUS

> This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

> Electronic copies: Available from the [National Kidney Foundation
> (NKF) Web
> site](http://www.kidney.org/professionals/kdoqi/guidelines_bp/index.htm).
>
> Print copies: Available from the National Kidney Foundation (NKF), 30
> East 33rd St., New York, NY 10016. These guidelines are also available
> on CD-ROM from NKF.

#### AVAILABILITY OF COMPANION DOCUMENTS

> None available

#### PATIENT RESOURCES

> None available

#### NGC STATUS

> This NGC summary was completed by ECRI on February 23, 2005.

#### COPYRIGHT STATEMENT

> K/DOQI is a trademark of the National Kidney Foundation, Inc. All
> rights reserved. No part of this publication may be reproduced or
> transmitted in any form or by any means, electronic or mechanical,
> including photocopy, recording, or any information storage retrieval
> system, without permission in writing from the National Kidney
> Foundation.

### DISCLAIMER

#### NGC DISCLAIMER

> The National Guideline Clearinghouse™ (NGC) does not develop, produce,
> approve, or endorse the guidelines represented on this site.
>
> All guidelines summarized by NGC and hosted on our site are produced
> under the auspices of medical specialty societies, relevant
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>
> Guidelines represented on the NGC Web site are submitted by guideline
> developers, and are screened solely to determine that they meet the
> NGC Inclusion Criteria which may be found at
> <http://www.guideline.gov/about/inclusion.aspx> .
>
> NGC, AHRQ, and its contractor ECRI Institute make no warranties
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>
> Readers with questions regarding guideline content are directed to
> contact the guideline developer.

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> © 1998-2008 National Guideline Clearinghouse
>
> Date Modified: 11/10/2008
>
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