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JNC8 versus Balanced Solutions

NephMadness Champion: JNC8

The 2014 winner of  NephMadness is JNC8. Since the publication of these guidelines in JAMA last December we have seen a proliferation of commentary and discussion about them. Prior posts chronicle some of this issues and concerns people and groups have had about the JNC8 guidelines. The win for JNC8 puts this very important topic square in the spotlight and deservedly so. Proper control of blood pressure is fundamental to maintaining kidney health. The JNC8 committee attempted to simplify the management of hypertension as below.

• 60 y/o or greater goal of 150/90 mm Hg (Strong Evidence)*
• 30 – 59 y/o DBP goal of <90 mm Hg (Strong Evidence), insufficient evidence for a SBP goal in this group so  SBP <140 (Expert Opinion)
• <30 y/o, goal <140/90 mm Hg (Expert Opinion)
• goal <140/90 mm Hg hypertensive adults with diabetes or nondiabetic CKD (Expert Opinion)*
• Start drug treatment with an ACEi, ARB, calcium channel blocker, or thiazide diuretic in nonblack patients, including those with diabetes. (Moderate Evidence)
• In black patients, including those with DM, a calcium channel blocker or thiazide-type diuretic as initial therapy.
• Initial or add-on antihypertensive therapy with an ACEi or ARB in persons with CKD to improve kidney outcomes. (Moderate Evidence)
  *major changes from JNC7

What do the adoption of the JNC8 guidelines do to hypertension management in general population compared to JNC7? Here is a recent JAMA paper describing this exact issue utilizing NHANES data:

Compared with the JNC 7 guideline, the 2014 BP guideline from the panel members appointed to the JNC 8 was associated with a reduction in the proportion of US adults recommended for hypertension treatment and a substantial increase in the proportion of adults considered to have achieved goal BP, primarily in older adults.

JNC8 guidelines do relax the blood pressure cut offs. However, this could mean less side-effects from over therapy, especially in older patients. It also relaxes the goal BP in patients with DM2 or CKD from 130/80 to 140/90 mm Hg. The JNC8 guidelines adhere closely to the Institute of Medicine (IOM) standards for establishing guidelines. Because of this, JNC8 is a completely different document from JNC7. It is a narrower document that doesn’t attempt to be a comprehensive guide to hypertension management. It’s use of IOM guidelines and its reliance on only randomized controlled trials shows the future of clinical guidelines. JNC8 also shines a light on areas in which we need to mature our understanding of hypertension. For these reasons, JNC8 is the champion of NephMadness 2014. Hypertension control is paramount to improving cardiovascular and kidney outcomes for patients. As more randomized clinical trials are performed and incorporated into guidelines, we will continue to see our understanding of hypertension evolve. We still await the results of the SPRINT trial, which according to ClinicalTrials.gov concludes in 2018. This compares BP goals in two groups: Standard arm and Intensive arm. Participants (no DM) are randomized into the Intensive BP arm will have a goal of SBP <120 mm Hg or age ≥75 years and SBP 130-139 mm Hg. Participants in the Standard arm will have a goal of SBP <140 mm Hg. Check out Clinical Trials.gov link for more information about this study. In conclusion, the JNC8 document is merely a guideline that was generated with information from well-done clinical trials. It also included expert opinion in situations where information is lacking. The bottom line is that treating hypertension requires an individual plan and approach. No guideline will ever be able to do this. We have seen several disappointments in the last few years in hypertension therapy research: from renal denervation (see SYMPLICITY), to renal artery stenting (see CORAL), to combination ACEi/ARB therapy (see NEPHRON-D). The field of hypertension continues to change and mature. Look at how the ACCORD-BP trial demonstrated how intensive therapy can lead to more side effects without much mortality benefit. What about balanced solutions? While this was a formidable foe indeed we are waiting on more definitive studies with proper controlling of groups. Also, including a more diverse patient population (such as floor vs. ER vs. ICU) and replicating studies like this in different centers are needed before balanced solutions can really make major waves in medicine.

As this year’s NephMadness comes to a close, we wanted to thank everyone for reading, commenting, and contributing to the Madness. NephMadness is not about the winners and losers – it’s about learning nephrology – and pushing ourselves to share and engage about a topic we are all passionate about. The end product of NephMadness to create a dialogue and a community. Thanks- The NephMadness Team

Click here to view all eAJKD content about NephMadness 2014!