More intensive lowering of systolic blood pressure (SBP) in patients with chronic kidney disease (CKD) not on dialysis may provide a survival benefit, new research confirms. The optimal SBP target remains unclear, however, and may vary by CKD stage.

In a systematic review and meta-analysis, published online before print in JAMA Internal Medicine, Rakesh Malhotra, MD, MPH, of the University of California in San Diego, and colleagues pooled data from 15,924 patients with stages 3 to 5 CKD (estimated glomerular filtration rate below 60 mL/min/1.73 m2) enrolled in 18 randomized controlled trials up to June 2016, including SPRINT (Systolic Blood Pressure Intervention Trial, NCT01206062). Nine trials supplied fresh, unpublished data.

The patients had an average SBP of 148 mm Hg at baseline. This fell 16 and 8 mm Hg, respectively, in the more and less intensively treated groups. What was considered “more” or “less” intensive varied by study.

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Over a median 3.6 years of follow up, 1293 patients died. Results showed a 14% lower risk for all-cause mortality with more intensive treatment. This advantage held in subgroup analyses and in a sensitivity analysis that excluded SPRINT data. No significant heterogeneity among studies was observed.

“Although additional studies and intensive monitoring for safety are warranted, these data support that the net benefits may outweigh the net harms of more intensive BP lowering in persons with CKD,” Dr Malhotra’s team concluded.

Still, the mean SBP in the intensive group fell to just 132 mm Hg – above the less than 120 mm Hg target considered physiologically normal. In an accompanying editorial, Csaba K. Kovesdy, MD, Fred Hatch Professor of Medicine at the University of Tennessee Health Science Center in Memphis, a Renal & Urology News editorial advisory board member, commented: “One could therefore interpret the results of this meta-analysis as solidifying existing evidence about the benefits of lowering BP to a range of 130 to 140 mm Hg but not as proof that truly intensive BP lowering (ie, to a target <120 mm Hg) is beneficial.” He emphasized that there are many outstanding questions that warrant research, including outcomes for advanced CKD patients.

Due to a lack of data, the reviewers could not examine all-cause mortality and SBP by CKD severity, which is a limitation.

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Malhotra R, Anh Nguyen H, 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. JAMA Intern Med. doi:10.1001/jamainternmed.2017.4377 [Epub ahead of print]

Kovesdy CP. The ideal blood pressure target for patients with chronic kidney disease—Searching for the sweet spot. JAMA Intern Med. doi:10.1001/jamainternmed.2017.4467 [Epub ahead of print]