Intensive Blood Pressure Control and Kidney Disease Progression
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?
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.
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.
The authors concluded that targeting BP below the current standard did not provide additional benefit for renal outcomes compared with standard treatment.
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.
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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