Acta Clinica Belgica International Journal of Clinical and Laboratory Medicine
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
BLOOD PRESSURE MANAGEMENT IN PATIENTS WITH CHRONIC KIDNEY DISEASE: AN APPRAISAL AND SUMMARY OF EXISTING GUIDELINES W Van Biesen, T Van de Velde, M Slabbaert, I Simoens, R Van Paemel & SN van der Veer To cite this article: W Van Biesen, T Van de Velde, M Slabbaert, I Simoens, R Van Paemel & SN van der Veer (2013) BLOOD PRESSURE MANAGEMENT IN PATIENTS WITH CHRONIC KIDNEY DISEASE: AN APPRAISAL AND SUMMARY OF EXISTING GUIDELINES, Acta Clinica Belgica, 68:6, 394-398 To link to this article: http://dx.doi.org/10.2143/ACB.3437
Published online: 30 May 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20 Download by: [McMaster University]
Date: 23 April 2016, At: 22:46
394
GUIDELINES ON HYPERTENSION
Congress Article
BLOOD PRESSURE MANAGEMENT IN PATIENTS WITH CHRONIC KIDNEY DISEASE: AN APPRAISAL AND SUMMARY OF EXISTING GUIDELINES Van Biesen W1, 2, Van de Velde T1, Slabbaert M1, Simoens I1, Van Paemel R1, van der Veer SN1, 3 Downloaded by [McMaster University] at 22:46 23 April 2016
1
ERBP Methods Support Team, Ghent University Hospital, Ghent, Belgium, 2Renal Division, Ghent University Hospital, Ghent Belgium, 3Department of Medical Informatics, Academic Medical Center, Amsterdam, the Netherlands Correspondence and offprint requests to: Wim Van Biesen, E-mail: [email protected]
ABSTRACT Background: Hypertension is a prevalent problem with huge impact on health and health care budgets. Several guidelines on how to manage blood pressure have been published, and it is unclear which one should be preferred. Methods: Eight guidelines dealing with blood pressure management of chronic kidney disease patients were evaluated for methodological quality by the AGREE II instrument by 4 appraisers. They were also analysed for consistency in their recommendations. Results: Most problematic domains were “applicability”, “stakeholder involvement” and “editorial independence”. Three guidelines scored below 50% for 5, and one for 4 of the 6 AGREE II domains. The guideline produced by Canadian Hypertension Education Program was preferred most, followed by KDIGO. There were discrepancies between the different guidelines with regard to blood pressure targets and thresholds, with the best and most recent advocating 140/90 mmHg. There was a consensus on the use of ACE-I/ARB’s in patients with but not for those without proteinuria. However, only two guidelines specify a second line treatment (thiazides), whereas others do not, although it is well known that most patients need more than one drug to control their blood pressure. Three out of eight guidelines did not provide guidance on life-style modification. Those who did, advocated different levels of sodium restriction,, weight control, and physical activity. Remarkably, 5 out of 8 guidelines did not specify how exactly blood pressure should be measured.
Acta Clinica Belgica, 2013; 68-6
Conclusion: Blood pressure guidelines seem to be of low methodological quality, with clear improvements for the ones produced the latest. Especially the “applicability” domain, evaluating how the guideline can be put into practice, seems problematic, with as biggest hurdles that it is unclear what should be second or third line treatments, and how blood pressure should be measured or defined. The most recent guidelines advocate an office blood pressure of 140/90 mmHg for patients with chronic kidney disease. Key words: hypertension; chronic kidney disease; guideline; AGREE II tool
INTRODUCTION Many physicians rely on clinical practice guidelines for the management of hypertension. However, it has never been evaluated whether existing clinical guidelines are of sufficient quality, or whether they recommend comparable strategies. It is also unclear whether for specific patients groups, such as the elderly and patients with chronic kidney disease (CKD), different management strategies should be used. We intended to analyse the methodological robustness of clinical practice guidelines on blood pressure management for patients with chronic kidney disease using the AGREE II tool (1). In addition, for several subtopics we compared recommendations between guidelines to identify differences and similarities, and looked for potential explanations of eventual differences.
doi: 10.2143/ACB.3437
GUIDELINES ON HYPERTENSION
MATERIALS AND METHODS
Downloaded by [McMaster University] at 22:46 23 April 2016
Appraisal of guidelines
We used the validated Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument (1) to assess the methodological quality of the guidelines dealing with management of blood pressure in chronic kidney disease patients as listed in table 16 of the KDIGO guideline on this topic. The 23-item instrument consists of six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability and editorial independence. Each guideline was independently appraised online by three different reviewers (permutations of MS, TV, IS, RP). The reviewers were all in training as general physician, and can thus be considered as being amongst the target audience of the selected guidelines. Each item within the six domains was rated by allocating a value from 1 to 7 (where 1 = ‘Strongly Disagree’ and 7 = ‘Strongly Agree’) based on the specific assessment criteria provided. Items for which the difference between the minimum and maximum individual score was > 2, were discussed during a consensus meeting. Appraisers could re-evaluate their score based on the group discussion. Based on the individual scores after the consensus meeting, we calculated the final score for each domain. These scores were obtained by summing all the item scores in a domain and then recalculating the total as a percentages of the maximum possible score using the formula: domain score in %= (obtained domain score – minimal score)/(maximal score-minimal score) and multiplied by 100. The minimal and maximal score for a domain would be the number of items multiplied by the number of appraisers and multiplied by 1 (Strongly Disagree) or 7 (Strongly Agree), respectively.
Comparing recommendations between guidelines
We compared recommendations between the guidelines for the following subtopics: 1° what blood pressure should be aimed at (targets); 2° at which level of blood pressure treatment should be started (thresholds); 3° which agents should be used as first and second line; 4° life style measures and non-medical approaches; 5° blood pressure monitoring and measuring.
rating below 50%), “stakeholder involvement” (with 5/8 guidelines having a score below 50%) and “editorial independence” (with 5/8 guidelines scoring below 50%). The guideline from Canadian Hypertension Education Program (CHEP) (6) scored not below 50% for any of the domains, whereas the guideline from the Kidney Disease: improving global outcomes (KDIGO) (8) scored below 50 only for applicability. Three guidelines (3, 5, 10) scored below 50% for 5, and one (4) for 4 of the 6 domains. The guideline produced by CHEP (6) was preferred by all those who appraised it, whereas KDIGO (8) was preferred by the person who did not appraise the CHEP.
Comparison of guideline recommendations Blood pressure targets Although 140/90 mmhg was mentioned most frequently as blood pressure target, there was some inconsistency in advocating lower blood pressure targets (130/80 mmHg), with some guidelines plainly advocating it whilst other stated that in fact evidence for this lower target was largely lacking. Threshold for starting treatment Three guidelines did not mention thresholds to start blood pressure lowering treatment, and the guideline users had to implicitly understand that the target and the threshold values were the same. First and second line treatment There was a consensus in advocating ACE-I or ARB’s as first line therapy in patients with proteinuria, usually defined as albuminuria> 30 mg/day or an equivalent of that formulation. For patients without proteinuria, there was inconsistency for ACE-I/ARB’s being first line, with four guidelines stating that other treatments do equally well, and one stating that ACE-I/ARBs versus other anti-hypertensive medications
RESULTS Included guidelines
We analysed nine documents providing guidance in English on management of blood pressure in CKD patients, the details of which are provided in table 1. The primary interest of the guideline producing bodies was hypertension (2-7) (N = 6) or kidney disease (8-10) (N = 3). One document (the Japanese Society of Hypertension Guideline) (11) could not be accessed, and was omitted from the analysis. All included guidelines were published between 2003 and 2012.
Methodological quality of the guidelines
The scores of the different guidelines for the six domains of AGREE II are presented in figure 1. According to AGREE II, the most problematic domains were “applicability” (with 6/8 guidelines having an overall
Figure 1: Mean scores (%) of the different guidelines for the different domains of AGREE II. Domain 1 = Scope and Purpose; Domain 2: Stakeholder involvement; Domain 3: Rigour of development; Domain 4: Clarity of presentation; Domain 5: Applicability; Domain 6: Editorial independence.
Acta Clinica Belgica, 2013; 68-6
395
Acta Clinica Belgica, 2013; 68-6
–– Not specified
–– Not specified
–– no recommendation on how to measure blood –– >140/90 mmHg if no pressure albuminuria >30 mg/ –– statements based on the assumption that day blood pressure is repeatedly measured in the –– >130/80 mmHg if office, unless specified otherwise albuminuria >30 mg/ day
Not specified
Not specified
Not specified
UK-RA10 2011
WHO4 2003
KDIGO8 2012
CARI3 2005
ESH5 2009
CSN9 2008 Not specified
140/90 mmHg
Not specified
140/90 mmHg
Not specified
–– Preference for home blood pressure monitoring >140/90 mmHg –– properly measured automated office blood pressure 135/85 mmHg is analogous to home based blood pressure >135/85 mmHg
CHEP6 2012
JNC7 2003
–– office blood pressure using auscultation >140/90 mmHg –– ambulatory blood pressure when white coat hypertension is suspected in patients without target organ damage
Blood pressure treshold
7
Blood pressure measurement –– BMI 18.5-24.9 –– DASH diet –– Sodium restriction 2.4 g/day –– Physical activity >30 ins/day
Life style interventions
1° ACE-I or ARB when proteinuria is –– Physical exercise 5-7 times/week present 30-60 mins 2° Thiazide diuretic –– BMI between 18-25 and Waist circumference
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
BLOOD PRESSURE MANAGEMENT IN PATIENTS WITH CHRONIC KIDNEY DISEASE: AN APPRAISAL AND SUMMARY OF EXISTING GUIDELINES W Van Biesen, T Van de Velde, M Slabbaert, I Simoens, R Van Paemel & SN van der Veer To cite this article: W Van Biesen, T Van de Velde, M Slabbaert, I Simoens, R Van Paemel & SN van der Veer (2013) BLOOD PRESSURE MANAGEMENT IN PATIENTS WITH CHRONIC KIDNEY DISEASE: AN APPRAISAL AND SUMMARY OF EXISTING GUIDELINES, Acta Clinica Belgica, 68:6, 394-398 To link to this article: http://dx.doi.org/10.2143/ACB.3437
Published online: 30 May 2014.
Submit your article to this journal
Article views: 21
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20 Download by: [McMaster University]
Date: 23 April 2016, At: 22:46
394
GUIDELINES ON HYPERTENSION
Congress Article
BLOOD PRESSURE MANAGEMENT IN PATIENTS WITH CHRONIC KIDNEY DISEASE: AN APPRAISAL AND SUMMARY OF EXISTING GUIDELINES Van Biesen W1, 2, Van de Velde T1, Slabbaert M1, Simoens I1, Van Paemel R1, van der Veer SN1, 3 Downloaded by [McMaster University] at 22:46 23 April 2016
1
ERBP Methods Support Team, Ghent University Hospital, Ghent, Belgium, 2Renal Division, Ghent University Hospital, Ghent Belgium, 3Department of Medical Informatics, Academic Medical Center, Amsterdam, the Netherlands Correspondence and offprint requests to: Wim Van Biesen, E-mail: [email protected]
ABSTRACT Background: Hypertension is a prevalent problem with huge impact on health and health care budgets. Several guidelines on how to manage blood pressure have been published, and it is unclear which one should be preferred. Methods: Eight guidelines dealing with blood pressure management of chronic kidney disease patients were evaluated for methodological quality by the AGREE II instrument by 4 appraisers. They were also analysed for consistency in their recommendations. Results: Most problematic domains were “applicability”, “stakeholder involvement” and “editorial independence”. Three guidelines scored below 50% for 5, and one for 4 of the 6 AGREE II domains. The guideline produced by Canadian Hypertension Education Program was preferred most, followed by KDIGO. There were discrepancies between the different guidelines with regard to blood pressure targets and thresholds, with the best and most recent advocating 140/90 mmHg. There was a consensus on the use of ACE-I/ARB’s in patients with but not for those without proteinuria. However, only two guidelines specify a second line treatment (thiazides), whereas others do not, although it is well known that most patients need more than one drug to control their blood pressure. Three out of eight guidelines did not provide guidance on life-style modification. Those who did, advocated different levels of sodium restriction,, weight control, and physical activity. Remarkably, 5 out of 8 guidelines did not specify how exactly blood pressure should be measured.
Acta Clinica Belgica, 2013; 68-6
Conclusion: Blood pressure guidelines seem to be of low methodological quality, with clear improvements for the ones produced the latest. Especially the “applicability” domain, evaluating how the guideline can be put into practice, seems problematic, with as biggest hurdles that it is unclear what should be second or third line treatments, and how blood pressure should be measured or defined. The most recent guidelines advocate an office blood pressure of 140/90 mmHg for patients with chronic kidney disease. Key words: hypertension; chronic kidney disease; guideline; AGREE II tool
INTRODUCTION Many physicians rely on clinical practice guidelines for the management of hypertension. However, it has never been evaluated whether existing clinical guidelines are of sufficient quality, or whether they recommend comparable strategies. It is also unclear whether for specific patients groups, such as the elderly and patients with chronic kidney disease (CKD), different management strategies should be used. We intended to analyse the methodological robustness of clinical practice guidelines on blood pressure management for patients with chronic kidney disease using the AGREE II tool (1). In addition, for several subtopics we compared recommendations between guidelines to identify differences and similarities, and looked for potential explanations of eventual differences.
doi: 10.2143/ACB.3437
GUIDELINES ON HYPERTENSION
MATERIALS AND METHODS
Downloaded by [McMaster University] at 22:46 23 April 2016
Appraisal of guidelines
We used the validated Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument (1) to assess the methodological quality of the guidelines dealing with management of blood pressure in chronic kidney disease patients as listed in table 16 of the KDIGO guideline on this topic. The 23-item instrument consists of six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability and editorial independence. Each guideline was independently appraised online by three different reviewers (permutations of MS, TV, IS, RP). The reviewers were all in training as general physician, and can thus be considered as being amongst the target audience of the selected guidelines. Each item within the six domains was rated by allocating a value from 1 to 7 (where 1 = ‘Strongly Disagree’ and 7 = ‘Strongly Agree’) based on the specific assessment criteria provided. Items for which the difference between the minimum and maximum individual score was > 2, were discussed during a consensus meeting. Appraisers could re-evaluate their score based on the group discussion. Based on the individual scores after the consensus meeting, we calculated the final score for each domain. These scores were obtained by summing all the item scores in a domain and then recalculating the total as a percentages of the maximum possible score using the formula: domain score in %= (obtained domain score – minimal score)/(maximal score-minimal score) and multiplied by 100. The minimal and maximal score for a domain would be the number of items multiplied by the number of appraisers and multiplied by 1 (Strongly Disagree) or 7 (Strongly Agree), respectively.
Comparing recommendations between guidelines
We compared recommendations between the guidelines for the following subtopics: 1° what blood pressure should be aimed at (targets); 2° at which level of blood pressure treatment should be started (thresholds); 3° which agents should be used as first and second line; 4° life style measures and non-medical approaches; 5° blood pressure monitoring and measuring.
rating below 50%), “stakeholder involvement” (with 5/8 guidelines having a score below 50%) and “editorial independence” (with 5/8 guidelines scoring below 50%). The guideline from Canadian Hypertension Education Program (CHEP) (6) scored not below 50% for any of the domains, whereas the guideline from the Kidney Disease: improving global outcomes (KDIGO) (8) scored below 50 only for applicability. Three guidelines (3, 5, 10) scored below 50% for 5, and one (4) for 4 of the 6 domains. The guideline produced by CHEP (6) was preferred by all those who appraised it, whereas KDIGO (8) was preferred by the person who did not appraise the CHEP.
Comparison of guideline recommendations Blood pressure targets Although 140/90 mmhg was mentioned most frequently as blood pressure target, there was some inconsistency in advocating lower blood pressure targets (130/80 mmHg), with some guidelines plainly advocating it whilst other stated that in fact evidence for this lower target was largely lacking. Threshold for starting treatment Three guidelines did not mention thresholds to start blood pressure lowering treatment, and the guideline users had to implicitly understand that the target and the threshold values were the same. First and second line treatment There was a consensus in advocating ACE-I or ARB’s as first line therapy in patients with proteinuria, usually defined as albuminuria> 30 mg/day or an equivalent of that formulation. For patients without proteinuria, there was inconsistency for ACE-I/ARB’s being first line, with four guidelines stating that other treatments do equally well, and one stating that ACE-I/ARBs versus other anti-hypertensive medications
RESULTS Included guidelines
We analysed nine documents providing guidance in English on management of blood pressure in CKD patients, the details of which are provided in table 1. The primary interest of the guideline producing bodies was hypertension (2-7) (N = 6) or kidney disease (8-10) (N = 3). One document (the Japanese Society of Hypertension Guideline) (11) could not be accessed, and was omitted from the analysis. All included guidelines were published between 2003 and 2012.
Methodological quality of the guidelines
The scores of the different guidelines for the six domains of AGREE II are presented in figure 1. According to AGREE II, the most problematic domains were “applicability” (with 6/8 guidelines having an overall
Figure 1: Mean scores (%) of the different guidelines for the different domains of AGREE II. Domain 1 = Scope and Purpose; Domain 2: Stakeholder involvement; Domain 3: Rigour of development; Domain 4: Clarity of presentation; Domain 5: Applicability; Domain 6: Editorial independence.
Acta Clinica Belgica, 2013; 68-6
395
Acta Clinica Belgica, 2013; 68-6
–– Not specified
–– Not specified
–– no recommendation on how to measure blood –– >140/90 mmHg if no pressure albuminuria >30 mg/ –– statements based on the assumption that day blood pressure is repeatedly measured in the –– >130/80 mmHg if office, unless specified otherwise albuminuria >30 mg/ day
Not specified
Not specified
Not specified
UK-RA10 2011
WHO4 2003
KDIGO8 2012
CARI3 2005
ESH5 2009
CSN9 2008 Not specified
140/90 mmHg
Not specified
140/90 mmHg
Not specified
–– Preference for home blood pressure monitoring >140/90 mmHg –– properly measured automated office blood pressure 135/85 mmHg is analogous to home based blood pressure >135/85 mmHg
CHEP6 2012
JNC7 2003
–– office blood pressure using auscultation >140/90 mmHg –– ambulatory blood pressure when white coat hypertension is suspected in patients without target organ damage
Blood pressure treshold
7
Blood pressure measurement –– BMI 18.5-24.9 –– DASH diet –– Sodium restriction 2.4 g/day –– Physical activity >30 ins/day
Life style interventions
1° ACE-I or ARB when proteinuria is –– Physical exercise 5-7 times/week present 30-60 mins 2° Thiazide diuretic –– BMI between 18-25 and Waist circumference
