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High Blood Pressure andChronic Kidney DiseaseFor People with CKD Stages 1–4www.kidney.org
National Kidney Foundation's Kidney DiseaseOutcomes Quality InitiativeDid you know that the National Kidney Foundation'sKidney Disease Outcomes Quality Initiative (NKFKDOQI) has guidelines that help your doctor andhealthcare team make important decisions about yourmedical treatment? The information in this booklet isbased on the NKF-KDOQI recommended guidelines.What is your stage of kidney disease?There are five stages of kidney disease. They are shownin the table below. Your doctor determines your stageof kidney disease based on the presence of kidneydamage and your glomerular filtration rate (GFR),which is a measure of your level of kidney function. Yourtreatment is based on your stage of kidney disease.Speak to your doctor if you have any questions aboutyour stage of kidney disease or your treatment.Stages of Kidney DiseaseStageDescriptionGlomerular Filtration Rate (GFR)*1Kidney damage (e.g., protein inthe urine) with normal GFR90 or above2Kidney damage with milddecrease in GFR60 to 893Moderate decrease in GFR30 to 594Severe reduction in GFR15 to 295Kidney failureLess than 15*Your GFR number tells your doctor how much kidney function you have.As chronic kidney disease progresses, your GFR number decreases.2National Kidney Foundation
Table of ContentsDid you know?.4What is chronic kidney disease?.5What is high blood pressure?.6How are high blood pressure and kidneydisease related?.7How do I know if my blood pressure is too high?.8How is blood pressure measured? How often should itbe checked?.9I have high blood pressure but am not sure if I have CKD.What should I do?.9What tests will I need if I have CKD?.10How often will I need to visit my doctor or clinic?.11What will my treatment for high blood pressureand CKD include?.12What kinds of changes will I need to make to my diet?.12Will I need to make other changes in my lifestyle?.15What about medications?.15What if I have CKD and diabetes?.16What if I have a kidney transplant?.16What can I do to help control my blood pressure?.17What can my family do?.18Where can I get more information?.19Key points to remember.20Test Your Knowledge.22www.kidney.org3
Did you know?nnnnn4M. ore than half the people with chronic kidney disease(CKD) have high blood pressure.High blood pressure increases the chance that kidneydisease will get worse.High blood pressure makes you more likely to developheart disease.Following your treatment plan carefully and keepingyour blood pressure under control can help toprevent these complications.Treatment for high blood pressure and CKD includesfollowing a healthy diet, exercising and takingmedications. Blood pressure should be controlledto less than 130/80 if you have CKD.National Kidney Foundation
nnIf you have kidney disease from diabetes or if youhave protein in your urine, the best blood pressuremedications for your treatment are angiotensinconverting enzyme (ACE) inhibitors or angiotensinreceptor blockers (ARBs).If you have CKD from diabetes or if you haveprotein in your urine, your doctor should prescribean ACE inhibitor or an ARB for you, even if yourblood pressure is normal.This booklet will answer your questions about high bloodpressure and kidney disease and tell you how to stayas healthy as possible when you have these conditions.This booklet is written for people who have high bloodpressure and CKD in stages 1–4. If you do not know yourstage of kidney disease, see the chart on the inside frontcover of this booklet and speak to your doctor.What is chronic kidney disease?Chronic kidney disease means the kidneys have beendamaged by conditions, such as diabetes, high bloodpressure or glomerulonephritis. As a result, the kidneysare less able to do the following jobs to help maintainhealth:nRemove wastes and extra fluid from your bodynRelease hormones that help to:Control blood pressurePromote strong bonesPrevent anemia by increasing the number of redblood cells in your bodywww.kidney.org5
nnKeep the right balance of important chemicals inyour blood, such as sodium, potassium, phosphorusand calciumMaintain the body’s balance of acid and base.When your kidneys are not working well, wastes canbuild to high levels in your blood and make you feelsick. Even before that, you may develop complicationslike high blood pressure, anemia (low blood count),weak bones, poor nutritional health and nervedamage. Kidney disease also makes you more likelyto develop heart and blood vessel disease. Theseproblems may happen slowly, over a long period oftime, often without symptoms. CKD may eventuallylead to kidney failure requiring dialysis or a kidneytransplant to maintain life. Early detection andtreatment can prevent or delay these complications.What is high blood pressure?Blood pressure is the force of your blood againstthe walls of your blood vessels as your heart pumpsblood around your body. If this pressure becomes toohigh, you are said to have high blood pressure, orhypertension.6National Kidney Foundation
How are high blood pressure and kidneydisease related?They are related in two ways:1. High blood pressure is a leading cause of CKD.Over time, high blood pressure can damageblood vessels throughout your body. This canreduce the blood supply to important organs likethe kidneys. High blood pressure also damagesthe tiny filtering units in your kidneys. As a result,the kidneys may stop removing wastes and extrafluid from your blood. The extra fluid in your bloodvessels may build up and raise blood pressureeven more.2. High blood pressure can also be a complicationof CKD. Your kidneys play a key role in keepingyour blood pressure in a healthy range. Diseasedkidneys are less able to help regulate bloodpressure. As a result, blood pressure increases.If you have CKD, high blood pressure makes it morelikely that your kidney disease will get worse and youwill have heart problems. Following your treatmentplan and keeping your blood pressure controlled canhelp keep your kidney disease from getting worse andprevent heart disease.www.kidney.org7
How do I know if my blood pressure is too high?The only way to tell if your blood pressure is too highis to have it measured. High blood pressure usuallycauses no symptoms. That is why it has been called a“silent killer.” A single high reading may not mean youhave high blood pressure. It should be confirmed onfollow-up visits to your doctor or clinic. Blood pressureis measured as two numbers. The top number, orsystolic blood pressure, is the pressure when your heartis beating. The bottom number, or diastolic bloodpressure, is the pressure when your heart is restingbetween beats. A blood pressure reading of 130/80 isread as 130 over 80.Normal blood pressure in adults 18 and older isless than 120/80. People who have blood pressurebetween 120 and 139 for the top number, or between80 and 89 for the bottom number, may be more likelyto develop high blood pressure unless they take stepsto prevent it. In general, blood pressure that staysat 140/90 or higher is considered high. However, forpeople who have diabetes or CKD, a blood pressureof 130/80 or higher is considered high.8National Kidney Foundation
How is blood pressure measured? How oftenshould it be checked?Blood pressure is usually checkedby using a blood pressure cuffaround your arm. It should bechecked every time you visit yourdoctor or clinic. You may also betaught to check your own bloodpressure at home. Keep a record ofyour daily blood pressure and showthis to your doctor at each visit.I have high blood pressure but am not sure if Ihave CKD. What should I do?Everyone who has high blood pressure has anincreased chance of developing CKD. You should askyour doctor about having the following tests:nnnA blood test for creatinine, a waste product frommuscle breakdown. This should be used to calculateyour glomerular filtration rate, or GFR. Your GFR is ameasure of your level of kidney function. If your GFRis too low, it may mean your kidneys are not ableto remove enough wastes and extra fluid from yourblood.A urine test for protein. Persistent protein in the urineis a sign of kidney damage. A higher urine proteinmeans there is an increased chance your kidneydisease may get worse and you may develop heartdisease.A urine test to check for red blood cells and whiteblood cells.www.kidney.org9
What tests will I need if I have CKD?In addition to checking your GFR and urine protein,you should have the following:nnDiagnosis of the type of CKD you have. This mayinclude an ultrasound to get a picture of yourkidneys to check for any problems in size orstructure or any blockages.Some tests to find out if you have an increasedchance of developing heart and blood vesseldisease, or if you already have heart problems.These tests will most likely include:An electrocardiogram (EKG)A blood test for glucose (sugar)A blood test for lipids (fatty substances in yourblood, such as cholesterol)Height and weight measurement to find yourbody mass index (BMI). This tells if you areoverweight.Your doctor will also talk to you about:nn10Any side effects or complications from yourmedicationsAny problems you may have in following yourtreatment plan.National Kidney Foundation
How often will I need to visit my doctor or clinic?Once you are stable with your treatment, you maynot need to visit your doctor or clinic as regularly. Yourdoctor will want to see you more often if:nYou start a new medicationnThe dose of your medication is changednYour kidney disease is getting worsenYour blood pressure is not controlled.At follow-up visits, your doctor will check:nYour blood pressurenYour GFRnYour urine protein levelnYour blood level of potassium. As kidney functiondecreases, potassium may build up to high levels inyour blood. This can be dangerous for your heart.Some of the best medicines for treating high bloodpressure and preventing further loss of kidneyfunction can also make the potassium go higher. Ifyour potassium level gets too high, you will need tomake some changes in your diet (see ”What kindsof changes will I need to make to my diet?” onpages 12–14).www.kidney.org11
What will my treatment for high bloodpressure and CKD include?A treatment plan should be developed especiallyfor you based on your stage of CKD. In some cases,your doctor may recommend that you see anotherdoctor with special training in kidney diseaseor high blood pressure. This doctor will help todevelop your treatment plan. The goals of yourtreatment are:nTo lower your blood pressure to less than 130/80nTo keep kidney disease from getting worsenTo lower your chance of getting heart disease.To help reach these goals, you will need acombination of lifestyle changes, such as followinga healthier diet and exercising more, and takingmedications.What kinds of changes will I need to maketo my diet?That will depend on your stage of CKD. In stages1–2, your doctor may recommend that you followa diet that is high in fruits, vegetables and dairyfoods, such as the DASH (Diet Approaches to StopHypertension). This diet is low in sugar and sodium.If you have any questions about your diet, speakto your doctor. Your doctor can refer you to aregistered dietitian who will help you work out adiet plan to meet your needs.12National Kidney Foundation
People with CKD instages 1–4 may alsobe asked to make thefollowing changes:nnnCut back onsodium (found inlarge amountsin table saltand foods withadded salt). Youshould not havemore than 2,400milligrams ofsodium each day.Cut down on foodsthat are high insaturated fatsand cholesterol.These can clog upyour arteries andincrease your riskfor heart and blood vessel disease.Control the amount of carbohydrates in your diet.Carbohydrates should only account for 50 percentto 60 percent of your daily calories. Carbohydratesare foods that turn to sugar when you digestthem. They are found in many foods, such asbread, rolls, tortillas, rice, pasta, potatoes, corn,dried beans, fruits and fruit juices, milkand yogurt.www.kidney.org13
If you have CKD in stages 3–4, you may be asked tomake some additional changes to keep CKD fromgetting worse and to prevent complications such asbone disease. You may need to:nnn14Control the amount of protein you eat. Ask yourdoctor how much protein you need each day. Yourdietitian can help you plan your meals to get theright amount of protein to meet your needs.Eat fewer foods that are high in phosphorus. Highlevels of phosphorus in your blood may lead tobone disease. Phosphorus is found in large amountsin dairy products like milk, cheese, pudding, yogurtand ice cream; in nuts and peanut butter; and inbeverages like cocoa, beer and dark cola drinks.Reduce the amount of potassium in your diet. Yourdoctor will check the amount of potassium in yourblood. Ask your doctor if your potassium level is toohigh. If it is, you will need to reduce your intake ofpotassium-rich foods. Your dietitian can teach youwhich foods are high and low in potassium and helpyou plan your meals to get the right amount.National Kidney Foundation
Will I need to make other changes in my lifestyle?Yes. The following steps can also help you reach yourtreatment goals:nnnnLose weight if you are overweight.Exercise at a moderate level for 30 minutes a dayon most days of the week. Always check with yourdoctor before starting an exercise program.Cut back on alcohol (no more than two drinks aday for men and one drink a day for women).Stop smoking if you are a smoker.What about medications?Your target blood pressure is below 130/80. To reachthis goal, you will probably need more than one typeof blood pressure pill. Your medications may include:nnnAn angiotensin converting enzyme (ACE) inhibitoror an angiotensin receptor blocker (ARB). Studieshave shown that these help to protect your kidneyfunction and lower your risk for heart disease.A diuretic or water pill.Other medications, such asbeta blockers or calciumchannel blockers, to helpreach your treatment goals.Be sure to take your medicationsexactly as prescribed by yourdoctor. Report any side effectsto your doctor right away. It maybe possible to lower your dose orwww.kidney.org15
switch you to another medication. Do not stop takingany of your medications on your own without lettingyour doctor know and following up to check your bloodpressure. Even though you are feeling well, uncontrolledhigh blood pressure could still damage vital organs likethe heart and kidneys. Remember, high blood pressureis a silent killer.What if I have CKD and diabetes?Controlling your blood sugar and blood pressureare the most important things you can do to keepkidney disease from getting worse and to preventother complications. Be sure to make the lifestylechanges recommended by your doctor and takeyour medications exactly as prescribed. If you havediabetes and CKD, an ACE inhibitor or ARB will be partof your treatment plan, even if your blood pressure isbelow 130/80. This is because these medications help toprotect your kidney function.What if I have a kidney transplant?Many kidney transplant recipients have high bloodpressure and CKD. It’s very important to reduce yourblood pressure to less than 130/80 in order to keepyour kidney transplant working well. If you have highblood pressure, be sure to follow the lifestyle changesrecommended by your doctor and to take your bloodpressure medications exactly as prescribed.16National Kidney Foundation
What can I do to help control my blood pressure?You can do a lot.nnnnnnnBe sure to keep all your scheduled appointmentswith your doctor.Ask your doctor how you can learn to take yourown blood pressure at home. Keep a record of yourdaily blood pressure and show this to your doctor ateach visit.Take your blood pressure pills exactly as prescribedby your doctor, even if you are feeling fine. Highblood pressure usually causes no symptoms.Report any side effects from your medicine to yourdoctor. Never stop taking any of your medicationson your own.To help you remember when to take yourmedications, try one of the special pill boxes withsmall compartments labeled with the days of theweek as well as the time of day. Watches with alarmsmay also be helpful. Ask your family members to helpremind you to take your medications.Follow your diet and exercise plan faithfully. Ifyou need help with your diet, ask your doctor torefer you to a registered dietitian. The dietitian willexplain the diet to you and help you develop ameal plan you can live with.Learn all you can about your treatment. Don’t beafraid to ask questions if there is something youdon’t understand. Bring a list of your questions whenyou go to the doctor.www.kidney.org17
What can my family do?It’s a good idea to get your whole family involvedin your care. It’s much easier to make lifestylechanges, such as following a healthier diet, exercisingmore and stopping smoking, if you take thesesteps together or if you have the support of yourfamily. Because high blood pressure often runs infamilies, some of your family members may also beat increased risk of developing high blood pressureand CKD. You should encourage them to learn allthey can about high blood pressure and to havetheir blood pressure checked at least once a year.A family history of high blood pressure and CKDincreases their risk of developing these conditions too.18National Kidney Foundation
Where can I get more information?nicChro s 1–4)andtageitionNutr isease (SDeyd?NeeKidnYouAreYouingGetttWhaeey Diseasonic KidnAbout ChriliesDiabetes and Your Eyes, Heart,Ner ves, Feet andKidneysir Famts and Thefor PatienA GuideWinnAgain ing the Figst Silent K htBlood PresillerssureHighandDiabetes:KeepYou ing YouShould r HeartKnoWhw A HealthenYouyWbouHavt Lip rgy.orgkidnewww.If you have questions, speak with your healthcareteam. They know you and can answer questionsabout you.If you want to read more about kidney disease, theNational Kidney Foundation has more than 50 otherpublications that cover many subjects, such as:nnnnnCKD risk factors like hypertension and diabetesComplications of chronic kidney disease, such ascardiovascular disease, anemia or bone problemsNutrition for CKD patients, information aboutcarbohydrates, protein, sodium, phosphorus andpotassiumTreating kidney disease earlyTreating kidney failure with transplantation ordialysis.www.kidney.org19
There are two ways to learn about the many freeresources available to you:nnCall the National Kidney Foundation at800.622.9010.Visit the National Kidney Foundation website(www.kidney.org/store). (All publications are free, butthere is a limit of five per person.)Becoming an educated patient is very important tobeing healthy!Key points to remembernnHigh blood pressure and kidney disease are closelyrelated. High blood pressure is both a cause and acomplication of kidney disease. Having high blood pressure increases the chance thatkidney disease will get worse and that heart problemswill develop.Keeping blood pressure well-controlled reduces thechance of these complications.n High blood pressure usually causes no symptoms.The only way to find out if your blood pressure istoo high is to have it measured. Your blood pressureshould be checked at every visit to your doctoror clinic.n 20National Kidney Foundation
If you have CKD, your doctor should also test yourblood to check your kidney function (GFR) and levelsof other chemicals in your blood such as potassium.Your urine will be checked for protein, a sign of kidneyproblems.n Your treatment will include making changes to ahealthier lifestyle and taking medications.n Your treatment goals are: to lower your blood pressureto less than 130/80; to keep kidney disease from gettingworse; and to reduce your chance of developing heartdisease.n You will probably need more than one type of highblood pressure pill to reach your target. These mayinclude: a diuretic or water pill, an ACE inhibitor or ARBto protect kidney function and other medications tohelp you reach your target blood pressure.n Report any problems to your doctor. Never stop takinga medication without speaking to your doctor.n Learn all you can about high blood pressure and CKD.Get involved in your own care.n Encourage family members to have their blood pressurechecked. They may also be at increased risk for highblood pressure and CKD.n www.kidney.org21
Test Your Knowledge: Take This True or False Quiz.1. High blood pressure increases the chance thatkidney disease will get worse.TrueFalse2. High blood pressure may be a complication ofkidney disease.TrueFalse3. High blood pressure causes many symptoms.TrueFalse4. The treatment for high blood pressure includeslifestyle changes and medications.TrueFalse5. Usually, one medication is enough to control highblood pressure in people with CKD.TrueFalse6. Getting regular exercise may help reduce yourblood pressure.TrueFalse7. If you have high blood pressure, you may needto increase sodium in your diet.TrueFalse8. If you have kidney disease, you are also atincreased risk for heart disease.TrueFalse9. The blood pressure goal for people with kidneydisease or diabetes is less than 140/90.TrueFalse10. You should never check your own blood pressure.TrueFalseSee answers on page 23.22National Kidney Foundation
Questions for My DoctorAnswers to Quiz on page 221. T6. T2. T7. F3. F8. T4. T9. F5. F10. Fwww.kidney.org23
National Kidney FoundationThe National Kidney Foundation (NKF) is dedicated to preventing kidney diseases,improving the health and well-being of individuals and families affected by thesediseases and increasing the availability of all organs for transplantation.With local offices nationwide, the NKF provides early detection screenings and othervital patient and community services. The Foundation conducts extensive public andprofessional education, advocates for patients through legislative action, promotesorgan donation and supports kidney research to identify new treatments.In 2009 NKF launched a groundbreaking multifaceted collaborative initiative to“END THE WAIT!” for a kidney transplant in the United States in 10 years by using provenstrategies to eliminate barriers to donation and institute best practices across the country.The NKF relies on individual and corporate donations, foundation and governmentgrants, membership and special events to support its range of programs, servicesand initiatives.National Kidney Foundation30 East 33rd StreetNew York, NY 10016800.622.9010www.kidney.orgWe proudly state that this publication is printed on recycledpaper that contains 10% post-consumer waste. The paperis also Forest Stewardship Council (FSC) certified whichguarantees it is made from trees that come from carefullymanaged and responsibly harvested forests that adhere tostrict environmental and socioeconomic standards. Pleaserecycle this publication when you are finished with it. 2010 National Kidney Foundation, Inc. All rights reserved. 11-10-0212 FBA
systolic blood pressure, is the pressure when your heart is beating. The bottom number, or diastolic blood pressure, is the pressure when your heart is resting between beats. A blood pressure reading of 130/80 is read as 130 over 80. Normal blood pressure in adults 18 and older is less than 120/80. People who have blood pressure
