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BACKGROUND: The real-world uptake of the 2021 Kidney Disease: Improving Global Outcomes (KDIGO) blood pressure (BP) guideline, which lowered the systolic BP target to <120 mmHg for patients with chronic kidney disease (CKD), is poorly understood. We examined the adoption of the 2021 KDIGO systolic BP target in clinical practice and its association with clinical outcomes.METHODS: The study was based on data from the Mass General Brigham healthcare network, an integrated healthcare system spanning primary to tertiary care in New England. In serial cross-sectional analysis, we identified ∼50 000 patients with CKD stage 3-4 in each year from 2020 to 2024 and assessed the annual proportion of patients within the 2021 KDIGO systolic BP target. In longitudinal analysis, we identified 18 996 patients with incident CKD stage 3-4 in 2014-2019 and evaluated the association between systolic BP above vs. within the target and clinical outcomes.RESULTS: In serial cross-sectional analysis, 18.3% of patients with CKD had systolic BP within the 2021 KDIGO target in 2020 (pre-guideline). The proportion changed only marginally after the guideline's publication-18.0% in 2021 (absolute difference, -0.3% [95% CI, -1.2 to 1.3]), 19.3% in 2022 (absolute difference, 1.0% [95% CI, -0.1 to 2.0]), 20.0% in 2023 (absolute difference, 1.7% [95% CI, 0.2 to 3.1]), and 21.9% in 2024 (absolute difference, 3.6% [95% CI, 1.9 to 5.3]). In longitudinal analysis, patients with systolic BP above the 2021 KDIGO target exhibited higher risks of cardio-kidney end points, lower risk of hypotension, and no differences in other safety end points compared to those within the target.CONCLUSIONS: Adoption of the 2021 KDIGO BP guideline remained limited in real-world practice. As of 2024, nearly 4 in 5 patients with CKD had systolic BP above the new guideline target.