Intensive Blood Pressure Control and Kidney Disease Progression

Study Questions:

What is the comparative impact of intensive blood pressure (BP) control (<130/80 mm Hg) with standard BP control (<140/90 mm Hg) on major renal outcomes in patients with chronic kidney disease (CKD) without diabetes?

Methods:

This was a systematic review and meta-analysis. Searches of PubMed, MEDLINE, Embase, and Cochrane Library for publications were performed. Randomized clinical trials that compared an intensive versus a standard BP target in nondiabetic adults with CKD, reporting changes in glomerular filtration rate (GFR), doubling of serum creatinine level, 50% reduction in GFR, end-stage renal disease (ESRD), or all-cause mortality were included. Random-effects meta-analyses for pooling effect measures were used for analysis with meta-regression and subgroup analyses for exploring heterogeneity. Differences in annual rate of change in GFR were the primary outcome and were expressed as mean differences with 95% confidence intervals (CIs). Differences in doubling of serum creatinine or 50% reduction in GFR, ESRD, composite renal outcome, and all-cause mortality were expressed as risk ratios (RRs) with 95% CIs.

Results:

A total of nine trials with 8,127 patients and a median follow-up of 3.3 years were identified. Compared with standard BP control, intensive BP control did not show a significant difference on the annual rate of change in GFR (mean difference, 0.07; 95% CI, −0.16 to 0.29 ml/min/1.73 m2/y), doubling of serum creatinine level or 50% reduction in GFR (RR, 0.99; 95% CI, 0.76-1.29), ESRD (RR, 0.96; 95% CI, 0.78-1.18), composite renal outcome (RR, 0.99; 95% CI, 0.81-1.21), or all-cause mortality (RR, 0.95; 95% CI, 0.66-1.37). Nonblacks and patients with higher levels of proteinuria showed a trend of lower risk of kidney disease progression with intensive BP control.

Conclusions:

The authors concluded that targeting BP below the current standard did not provide additional benefit for renal outcomes compared with standard treatment.

Perspective:

This systematic review and meta-analysis of nondiabetic adults with CKD reports no differences in renal outcomes comparing intensive and standard BP-lowering strategies during a median follow-up of 3.3 years. However, nonblacks and patients with higher levels of proteinuria showed a trend of lower risk of kidney disease progression with intensive BP lowering treatments, which should be considered hypothesis generating. At this time, routine use of intensive BP control (<130/80 mm Hg) in patients with CKD for renoprotection does not appear justified.

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention, Hypertension

Keywords: Blood Pressure, Creatinine, Diabetes Mellitus, Disease Progression, Glomerular Filtration Rate, Hypertension, Kidney Failure, Chronic, Metabolic Syndrome X, Primary Prevention, Proteinuria


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