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The incidence of cardiovascular disease (CVD) is very high in patients with chronic kidney (CKD) disease and in kidney transplant recipients. Indeed, available evidence for these patients suggests that the 10‐year cumulative risk of coronary heart disease is at least 20%, or roughly equivalent to the risk seen in patients with previous CVD. Recently, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (K/DOQI) published guidelines for the diagnosis and treatment of dyslipidemias in patients with CKD, including transplant patients. It was the conclusion of this Work Group that the National Cholesterol Education Program Guidelines are generally applicable to patients with CKD, but that there are significant differences in the approach and treatment of dyslipidemias in patients with CKD compared with the general population. In the present document we present the guidelines generated by this workgroup as they apply to kidney transplant recipients. Evidence from the general population indicates that treatment of dyslipidemias reduces CVD, and evidence in kidney transplant patients suggests that judicious treatment can be safe and effective in improving dyslipidemias. Dyslipidemias are very common in CKD and in transplant patients. However, until recently there have been no adequately powered, randomized, controlled trials examining the effects of dyslipidemia treatment on CVD in patients with CKD. Since completion of the K/DOQI guidelines on dyslipidemia in CKD, the results of the Assessment of Lescol in Renal Transplantation (ALERT) Study have been presented and published. Based on information from randomized trials conducted in the general population and the single study conducted in kidney transplant patients, these guidelines, which are a modified version of the K/DOQI dyslipidemia guidelines, were developed to aid clinicians in the management of dyslipidemias in kidney transplant patients. These guidelines are divided into four sections. The first section (Introduction) provides the rationale for the guidelines, and describes the target population, scope, intended users, and methods. The second section presents guidelines on the assessment of dyslipidemias (guidelines 1–3), while the third section offers guidelines for the treatment of dyslipidemias (guidelines 4–5). The key guideline statements are supported mainly by data from studies in the general population, but there is an urgent need for additional studies in CKD and in transplant patients. Therefore, the last section outlines recommendations for research.

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In the last 10 years we have evaluated 63 patients with acute crescentic rapidly progressive glomerulonephritis (AC-RPGN), 46 of whom received pulse methylprednisolone (PM). The groups consisted of patients with no immune deposits, immune complexes, vasculitis, and antiglomemlar basement membrane (anti-GBM) disease. Seventy-nine percent of non-anti-GBM patients improved versus 25% of unpulsed, p < 0.005; 70% stopped dialysis (D) versus none of unpulsed, p < 0.009; creatinine decreased from 8.6 before to 2.7 mg/dl after PM, p < 0.05. Percent crescents and oligoanuria did not influence PM results, but did with conventional therapy (prednisone, cytotoxics, anticoagulants, supportive treatment). Seventeen percent of anti-GBM patients improved, none stopped D. In anti-GBM patients, serum creatinine < 6 mg/dl was associated with a favorable response to PM, p = 0.045. Twenty-one percent of responding patients lost function at 19.8 months. The long-term response for non-anti-GBM patients was 62%. Patients with low chronicity on biopsy had shorter duration of disease (p = 0.006) and 92% initial, 85% long-term improvement; those with high chronicity had an immediate 71 %, and 36% long-term response rate, p < 0.02. Thus, PM is effective and appears superior to conventional therapy in treatment of non-anti-GBM AC-RPGN.

Hypertension is common in CKD, and is a risk factor for faster progression of kidney disease and development and worsening of 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). BACKGROUND The Joint National Committee (JNC) for Prevention, Detection, Evaluation and Treatment of High Blood Pressure issues regular reports that are meant to provide guidance for primary-care clinicians. The seventh report (JNC 7), issued in 2003, suggests stratification of risk for CVD in individuals with high blood pressure to determine the intensity of treatment. Individuals at highest risk should receive most intensive treatment, including prompt pharmacological therapy, a lower blood pressure goal, and use of specific antihypertensive agents for "compelling indications," including CKD. 5,5a Hypertension is common in CKD, affecting 50% to 75% of individuals. The Work Group for this K/DOQI Guideline on Hypertension and Antihypertensive Agents in CKD proposes recommendations for all patients with CKD, whether or not they have hypertension. Guideline 1 reviews the goals of antihypertensive therapy; multi-intervention strategies for CKD; and possible discrepancies between goals of slowing progression of CKD and reducing CVD risk. It concludes with a review of key recommendations of the guidelines and compares the recommendations to those made by the JNC 7, as well as with previous reports by the NKF and ADA. Limitations, implementation issues, and research recommendations are covered in subsequent guidelines. RATIONALE Definitions Antihypertensive therapy includes lifestyle modifications and pharmacological therapy that reduce blood pressure, in patients with or without hypertension. Lifestyle modifications include changes in diet, exercise, and habits that may slow the progression of CKD or lower the risk of CVD. These guidelines focus specifically on lifestyle modifications that lower blood pressure. Lifestyle modifications are discussed in more detail in Guideline 6. Pharmacological therapy includes selection of antihypertensive agents and blood pressure goals. Antihypertensive agents are defined as agents that lower blood pressure and are usually prescribed to hypertensive individuals for this pu...