An intensive systolic blood pressure (BP) target of less than 130 mm Hg may reduce the risk for early death compared with a standard target of less than 140 mm Hg in patients with stage 3 to 4 chronic kidney disease (CKD) who are not on intensive glycemic therapy, according to a new study.
Previous randomized controlled trials (RCTs) have not consistently demonstrated a mortality benefit with intensive BP management. So Rahul Aggarwal, MD, of Boston University School of Medicine, and colleagues conducted a meta-analysis of 4 large BP trials involving CKD patients: AASK (African American Study of Kidney Disease and Hypertension), ACCORD (Action to Control Cardiovascular Risk in Diabetes), MDRD (Modification of Diet in Renal Disease), and SPRINT (Systolic Blood Pressure Intervention Trial).
Pooled results showed that mean systolic BP had declined 12 mm Hg more in the intensive target group (2509 patients) than the standard target group (2474 patients) at 1 year: 125.0 vs 136.9 mm Hg, Dr Aggarwal’s team reported in Hypertension. Despite a trend toward better survival with intensive BP targeting, the results were nonsignificant. Yet investigators found a significant 21% reduction in all-cause mortality after excluding patients with higher estimated glomerular filtration rates (60 mL/min/1.73 m2 and above) and ACCORD participants with intensive glycemic control (targeting a hemoglobin A1c less than 6%). Results did not vary by age, sex, race, or baseline systolic or diastolic BP.
“Given that our results provide RCT-quality evidence that intensive targeting improves clinical outcomes, specifically, all-cause mortality events, future guidelines should consider this evidence,” Dr Aggarwal and colleagues wrote. “We think that guidelines recommending an above 130 mm Hg systolic target, such as European Society of Cardiology, may be too conservative and that the American College of Cardiology / American Heart Association recommendation of <130 mm Hg SBP for patients with CKD is appropriate.”
The authors of an accompanying editorial agreed. “In sum, the study by Aggarwal et al strongly supports the notion that intensive BP reduction improves survival in patients with CKD and hypertension, who are plagued with a very high mortality rate,” Fabio Angeli, MD, of the Hospital S. Maria della Misericordia in Italy, and coauthors wrote. “The study by Aggarwal et al lends further support to tight BP control in these patients, as recommended by the 2017 American College of Cardiology / American Heart Association guidelines. The concept of lower safety boundaries for treated BP endorsed by the European Hypertension Guidelines should be reconsidered.”
The researchers in the current study could not assess proteinuria, which is a limitation. In addition, they could not gauge potential adverse effects from intensive management.
Aggarwal R, Petrie B, Bala W, Chiu N. Mortality outcomes with intensive blood pressure targets in chronic kidney disease patients: A pooled individual patient data analysis from randomized trials. Hypertension. DOI:10.1161/HYPERTENSIONAHA.119.12697Hypertension.
Angeli F, Verdecchia P, Reboldi G. Tight blood pressure control saves lives in hypertensive patients with chronic kidney disease. Hypertension. DOI:10.1161/HYPERTENSIONAHA.119.12855.