D Very low The estimate of effect is very uncertain, and often will be far from the truth. methods for guideline development Table 16 | Existing major guidelines and recommendations on hypertension and anti-hypertensive agents in CKD Year Group Target CKD population Recommended BP goal (mm Hg) Recommended preferred anti-hypertensive agent(s) 2003 Seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure143 Stage 3 CKD, macroalbuminuria, kidney-transplant recipients o130/80 CKD 3 or macroalbuminuria: ACE-I or ARB in combination with a diuretic Kidney-transplant recipients: No particular class of agents superior 2003 World Health Organization/International Society of Hyper- tension Statement on Management of Hypertension243 http://www.who.int/cardiovascular_diseases/guidelines/ hypertension_guidelines.pdf Type 1 DM with nephropathy Type 2 DM with nephropathy Non-diabetic nephropathy o130/80 Type 1 DM with nephropathy: ACE-I Type 2 DM with nephropathy: ARB Non-diabetic nephropathy: ACE-I 2003 European Society of Hypertension European Society of Cardiology Guidelines for the Management of Arterial DM, CKD o130/80 (if urine protein 41 g/d is present, lower target to lower protein if possible) CKD: Diuretic Type 1 DM with nephropathy: ACE-I Type 2 DM with nephropathy: ARB Non-diabetic nephropathy: ACE-I Proteinuria: ACE-I or ARB 2006 Caring for Australasians with Renal Impairment (CARI) Guidelines: Prevention of Progression of Kidney Disease http://www.cari.org.au/ckd_prevent_list_published.php DM, CKD CKD in general: if urine protein 41 g/d if urine protein 0.25 1 g/d if urine protein o0.25 g/d DKD: o130/85 for patients 450 years of age o120/70 75 for those o50 years of age Non-DKD: Regimens including ACE-I more effective than those not including ACE-I in slowing CKD progression in non-DKD Combination therapy of ACE-I and ARB slows progression of non-DKD more effectively than either single agent ACE-I more effective than beta-blockers and dihydropyridine CCB in slowing progression of CKD Beta-blockers more effective than dihydro- pyridine CCB in slowing CKD progression, especially in the presence of proteinuria DKD: ACE-I for all patients with diabetes and hypertension ACE-I for all patients with diabetes and microalbuminuria or overt nephropathy, independent of BP and GFR ARB provides specific renoprotection in diabetic nephropathy, beyond their anti-hypertensive benefit There is insufficient evidence that ACE-I and ARB combination are of additive specific benefit in diabetic nephropathy, beyond additional anti-hypertensive benefit 2008 Canadian Society of Nephrology Guidelines on Management of CKD238 DM, CKD o130/80 Non-DKD: ACE-I or ARB should be included in the regimen if urine ACR 430 mg/mmol ACE-I, ARB, thiazides, long-acting CCB, or beta- blockers (for patients older than 60 years) should be included in the regimen if urine ACR o30 mg/mmol (o300 mg/g) DKD: ACE-I or ARB should be included in the regimen 2009 Reappraisal of European Guidelines on Hypertension Management: a European Society of Hypertension Task Force Document353 DM, CKD Initiate treatment for systolic BP 4130 and diastolic ACE-I or ARB, but combination therapy with other agents most likely needed to control BP 2009 Japanese Society of Hypertension Guidelines for the Management of Hypertension452 For those with urine protein ACE-I or ARB should be the first choice of therapy and dose should be titrated by urinary albumin excretion (o30 mg/g for diabetic nephropathy and o300 mg/g for glomerulonephritis) For diuretics, thiazides should be used if GFR , and loop diuretics should Table 16 continued on following page methods for guideline development account explicit judgments about the relative importance of each outcome. 