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BP Control & Risk of Mortality in Patients with CKD

JAMA Intern Med; ePub 2017 Sep 5; Malhotra, et al

Significantly lower mortality risk among persons with hypertension and chronic kidney disease (CKD) was evident in those randomized to more intensive blood pressure (BP) control, according to a recent study. The systematic review and meta-analysis of 18 randomized clinical trials (RCTs) investigated if more intensive compared with less intensive BP control is associated with reduced mortality risk in persons with CKD stages 3 to 5. Researchers found:

  • There were 1,293 deaths among 15,924 participants with CKD.
  • The mean baseline systolic BP (SBP) was 148 (16) mmHg in both the more intensive and less intensive arms.
  • The mean SBP dropped by 16 mmHg to 132 mmHg in the more intensive arm and by 8 mmHg to 140 mmHg in the less intensive arm.
  • More intensive vs less intensive BP control resulted in 14.0% lower risk of all-cause mortality (OR, 0.86).
Citation:

—Malhotra R, Nguyen HA, Benavente O, et al. Association between more intensive vs less intensive blood pressure lowering and risk of mortality in chronic kidney disease stages 3 to 5. A systematic review and meta-analysis. [Published online ahead of print September 5, 2017]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.4377.

Commentary:

The current JNC 8 guidelines recommend a BP target of <140/90 mmHg for individuals with CKD. Since publication of the guidelines, the SPRINT trial showed a BP <120 mmHg to have better outcomes, specifically lower CVD risk and lower all-cause mortality risk, than a BP target <140 mmHg. About a third of patients in SPRINT had GFRs between 20-59 mL/min/1.73 m2 (CKK Stages 3-4) and there was no difference in outcomes between the cohort with and without CKD. Of note, in the intensively treated group, there was a higher rate of acute kidney injury. Other trials have not shown a benefit to more intensive treatment.2,3 This meta-analysis suggests a benefit of treatment of BP in patients with CKD to a more rigorous goal than 140 mmHg, but notably the BP achieved in the intensive group was an average of 132 mmHg, not <130 mmHg, and certainly not <120 mmHg. What are we to do with this information while we wait for the new guidelines to be released? In patients with CKD, it seems important to try to achieve a BP <140 mmHg, and likely <135 mmHg, with evidence suggesting—but not confirming—that a target <130 mmHg may be beneficial. —Neil Skolnik, MD

  1. Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103-2116.
  2. Klahr S, Levey AS, Beck GJ, et al. Modification of diet in renal disease study group. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. N Engl J Med. 1994;330(13):877-884.
  3. Wright JT Jr, Bakris G, Greene T, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: Results from the AASK trial. Published correction appears in JAMA. 2006;295(23):2726]. JAMA. 2002;288(19):2421-2431.

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