Intensive blood pressure lowering linked to decreased mortality in patients with chronic kidney disease

1. In a meta-analysis of randomized trials evaluating blood pressure control in patients with stage 3-5 chronic kidney disease (CKD), more intensive blood pressure lowering was associated with reduction in all-cause mortality.

2. In sensitivity analysis, trials demonstrating a greater blood pressure reduction were associated with greater reductions in all-cause mortality.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Hypertension remains one of the most common modifiable risk factors for cardiovascular disease, with appropriate management demonstrating reductions in cardiovascular morbidity and mortality. The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that intense blood pressure (BP) control led to reductions in mortality. Concern remains with regards to generalizing the SPRINT results to patients at risk for toxicity related to antihypertensive medications such as those with advanced renal insufficiency. This study evaluated the all-cause mortality difference across a systematic review of blood pressure control trials that included patients with stage 3-5 chronic kidney disease (CKD). The analysis demonstrated that there was an overall benefit to more intensive blood pressure control strategies in reducing all-cause mortality.

The study adds further evidence towards expanding the indication to pursue more aggressive blood pressure control in patients with renal insufficiency. The main strength was inclusion of only high quality studies and a large number of patients. The main limitations of the study include the inability to better stratify the results by degree of renal dysfunction, proteinuria, or other important covariates. Finally, there was heterogeneity between studies with regards to definition of more and less intensive BP targets.

Click to read the study, published in JAMA Internal Medicine

Relevant Reading: Effects of Intensive BP Control in CKD

In-Depth [systematic review and meta-analysis]: This study is a systematic review and meta-analysis of open-label and double-blinded randomized controlled trials and had compared either BP control to no BP control, or two different BP targets. Data for participants who were 18 years or older with stage 3 to 5 (eGFR <60 mL/min) CKD. Studies with no mortality data published had data obtained through contact with the trials’ original investigators, but those trials without mortality data available were excluded. The primary endpoint was all-cause mortality during the active treatment phase of the studies.

Of the 30 RCTs initially included, mortality data from 18 trials were available. The baseline mean (standard deviation) SBP was 148 (16) mmHg, which dropped to 132 mmHg in the intensive BP control group, and 140 mmHg in the less intensive group. Compared to less intensive control, the more aggressive management was associated with an all-cause mortality hazard ratio of 0.86 (95% CI, 0.76-0.97; p = 0.01). In subgroup analysis, a greater difference achieved between study groups showed greater mortality benefit.

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