Association of Intensive Blood Pressure Control and Kidney Disease Progression in Nondiabetic Patients With Chronic Kidney Disease

Abstract

IMPORTANCE The optimal blood pressure (BP) target remains debated in nondiabetic patients with chronic kidney disease (CKD). OBJECTIVE To compare intensive BP control (<130/80 mm Hg) with standard BP control (<140/90 mm Hg) on major renal outcomes in patients with CKD without diabetes. DATA SOURCES Searches of PubMed, MEDLINE, Embase, and Cochrane Library for publications up to March 24, 2016. STUDY SELECTION Randomized clinical trials that compared an intensive vs 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. DATA EXTRACTION AND SYNTHESIS Random-effects meta-analyses for pooling effect measures. Meta-regression and subgroup analyses for exploring heterogeneity. MAIN OUTCOMES AND MEASURES Differences in annual rate of change in GFR were expressed as mean differences with 95% 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 We identified 9 trials with 8127 patients and a median follow-up of 3.3 years. 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 m 2 /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, 0.81; 95% CI, 0.64-1.02). Intensive BP control reduced mortality (RR, 0.78; 95% CI, 0.61-0.99) in sensitivity analysis when the study populations were strictly restricted to those without diabetes. Nonblacks and patients with higher levels of proteinuria showed a trend of lower risk of kidney disease progression with intensive BP control. CONCLUSIONS AND RELEVANCE Targeting BP below the current standard did not provide additional benefit for renal outcomes compared with standard treatment during a follow-up of 3.3 years in patients with CKD without diabetes. However, nonblack patients or those with higher levels of proteinuria might benefit from the intensive BP-lowering treatments.

Association of Acute Kidney Injury with Cardiovascular Events and Death in Systolic Blood Pressure Intervention Trial

“…Additionally, in patients without CKD, a dose-response relationship was observed in which a greater reduction in mean arterial pressure associated with greater eGFR decline, and the balance between cardiovascular benefits and kidney risks were less favorable with larger blood pressure reductions [14]. A systematic review of 9 clinical trials conducted in participants with non-diabetic CKD demonstrated that compared to standard treatment, intensive blood pressure treatment did not reduce rates of overall eGFR decline, reaching 50% eGFR decline, or serum creatinine doubling [20]. In the Action to Control Cardiovascular Risk in Diabetes trial of patients with type 2 diabetes randomized to a target systolic blood pressure of < 120 versus < 140 mm Hg, eGFR was lower and risk of reaching eGFR < 30 mL/min/1.73 m 2 was higher without benefit on cardiovascular outcomes.…”

Intensive versus Usual Control of Hypertension in the Prevention of Cardiovascular and Renal Outcomes: A Cumulative Meta-Analysis of Randomized Controlled Trials

“…A previous meta-analysis based on 9 investigations in chronic kidney disease patients found that IBP control did not provide additional benefits for renal outcomes when compared with standard BP control during the follow-up period of 3.3 years, whereas this effect was not observed in diabetic patients [43]. However, the authors did not investigate the treatment effects of IBP control on cardiovascular outcomes.…”

Risk factor management in a contemporary Australian population at increased cardiovascular disease risk

“…Although a target of <130/80 mmHg has been recommended for individuals with diabetes or micro‐ or macroalbuminuria, the appropriateness of a BP target lower than <140/90 in diabetic patients is the subject of debate . There is also uncertainty about the appropriateness of a BP target lower than <140/90 in patients with CKD . A third of diabetic participants with HbA1c levels above the target and under‐utilisation of antiplatelet therapies in participants with vascular disease and anticoagulant therapy in participants with AF also demonstrate therapeutic inertia.…”