Table 1.
Is more intensive blood pressure good for the kidney?
| Reference | Population | BP targets | BP achieved | Results | Major findings associated to intensive BP lowering | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Intensive | Standard | Intensive | Standard | ||||||||
| Randomized clinical trial | |||||||||||
| Klahr et al.17(MDRD) (1994) | 840 CKD, mean age 52 y, female 40% Study A (n = 585): GFR 25‐55; Study B (n = 255): GFR 13‐24; proteinuria level <10 g/d | MAP < 92 | MAP < 107 | 126/77 | 134/81 | Rate of change in GFR: NS | No additional renal benefit | ||||
| Toto et al.41 (1995) | 77 HT with CKD; mean age 56 y; female 37%; serum Cr 1.6‐7.0; GFR ≤70; proteinuria ≤2 g/d | DBP 65‐80 | DBP 85‐95 | 133/81 | 138/87 | Rate of decline in GFR: NS | No additional renal benefit | ||||
| Turner et al.42 (UKPDS 38) (1998) | 1148 Type 2 DM with HT; mean age 56 y, female 44%; albuminuria 21% | 150/85 | <180/85 | 144/82 | 154/87 | Renal failure: HR 0.58; 95% CI: 0.15‐2.2; P = 0.29 | No additional renal benefit | ||||
| Ruilope et al.43 (HOT) (2001) and Hansson et al.44 (HOT) (1998) | 18 790 HT with DBP 110‐115; mean age 62 y, female 47%; CKD 18% | DBP 80 | DBP 85 | DBP 90 | 140/81 | 141/83 | 143/85 | Creatinine increase >30% to a value >2.0 mg/dL: NS | No additional renal benefit | ||
| Schrier et al.45(2002) | 75 ADPKD with CKD and LVH; mean age 41 y; female 45%; CrCl >30; proteinuria ≤3 g/d | <120/80 | 135‐140/85‐90 | MAP 90 ± 5 | MAP 101 ± 4 | Change in GFR: NS | No additional renal benefit | ||||
| Wright Jr et al.18(AASK) (2002) | 1094 CKD African Americans; mean age 55 y; female 39%; GFR 20‐70; proteinuria ≤2.5 g/d | MAP <92 | MAP 102‐107 | 128/78 | 141/85 | Rate of change in GFR: NS | No additional renal benefit | ||||
| Ruggenenti et al.19 (REIN‐2) (2005) | 339 CKD with proteinuria 1‐3 g/d and GFR <45, or proteinuria >3 g/d and GFR <70; mean age 54 y; female 26% | <130/80 | DBP < 90 | 130/80 | 134/82 | ESRD: NS | No additional renal benefit | ||||
| JATOS Study Group,46(2008) | 4419 with serum Cr <1.5; mean age 74 y; female 64%; CKD 57% | SBP < 140 | SBP 140‐160 | NA | NA | Change in GFR; doubled Cr or ESRD: NS | No additional renal benefit | ||||
| Cushman et al.27 (ACCORD) (2010) | 4733 Type 2 DM with HT; mean age 62 y; female 47%; CKD 37% | SBP < 120 | SBP < 140 | SBP 119.3 | SBP 133.5 | Renal failure: NSDevelopment of macroalbuminuria: NSDevelopment of microalbuminuria: HR 0.84; 95% CI: 0.72‐0.97; P = 0.019 | No additional renal benefit except for reduction in the incidence of albuminuria | ||||
| Benavente et al.47 (SPS3) (2013) | 3020 recent, MRI‐defined symptomatic lacunar infarctions; mean age 63 y; female 37%; CKD 16% | SBP < 130 | SBP 130‐149 | 127/70 | 137/76 | eGFR decline >30%: HR 1.4; 95% CI: (1.1‐1.6) | Worse renal outcome | ||||
| Schrier et al.48 (HALT‐PKD) (2014) | 558 ADPKD with CKD; mean age 37 y; female 49%; GFR >60; proteinuria ≤0.5 g/d (Study A) | 95‐110/60‐75 | 120‐130/70‐80 | Difference: SBP, 13.4/DBP, 9.3 | Annual % change in kidney volume: NS | No additional renal benefit | |||||
| Wright Jr et al.23 (SPRINT) (2015) | 9361 with GFR ≥20 and proteinuria <1 g/d; mean age 68 y; female 36%; CKD 28% | SBP < 120 | SBP < 140 | SBP 121.5 | SBP 134.6 | 50% reduction in GFR or ESRD: NS | No additional renal benefit | ||||
| Post‐hoc analysis in randomized clinical trial | |||||||||||
| Weber et al.49 (ACCOMPLISH) (2016) | 6459 Diabetes with in‐treatment PAS > 110; mean age 67 y; female 42%; CKD 17% | <120 | <130 | <140 | >140 | 116.3 | 125.5 | 134.4 | 150.4 | Serum creatinine increase ≥50%:lowest event rates in the SBP 130‐139 but further reductions below 130 were associated with increases in this outcome | Worse renal outcome with very low BP values |
| 4246 Not Diabetes with in‐treatment PAS > 110; mean age 70 y; female 34%; CKD 19% | 116.3 | 125.5 | 134.6 | 149.8 | |||||||
| Beddhu et al.28 (SPRINT) (2017) | 6662 SPRINT participants with an eGFR ≥60; mean age 66 y; female 34%; CKD 0% | SBP < 120 | SBP < 140 | The average between‐group difference in SBP after 6 mo was 15.0 mm Hg | >30% decrease in GFR to a value <60: HR 3.54, CI: 2.50‐5.02, P < 0.001 | Worse renal outcome | |||||
| Cheung et al.24 (SPRINT) 2017 | 2646 SPRINT participants with an eGFR < 60; mean age 72 y; female 40%CKD 100% | SBP < 120 | SBP < 140 | 123/66 | 135/72 | Composite of >50% decrease in eGFR from baseline or ESRD: NSAfter the initial 6 mo, the intensive group had a slightly higher rate of change in eGFR (20.47 vs 20.32 mL/min per 1.73 m2 per year; P = 0.03 | No additional renal benefit | ||||
| Beddhu et al.50 (SPRINT & ACCORD) (2017) | 11 026 SPRINT and ACCORD participants with an eGFR ≥60; mean age 61 y in ACCORD and 64 in SPRINT; female 46% in ACCORD and 34% in SPRINT; CKD 0% | SBP < 120 | SBP < 140 | The average between group difference in SBP was 13.9 mm Hg in the ACCORD trial and 15.2 mm Hg in SPRINT | >30% decrease in GFR to a value <60: HR 3.49 (2.42‐5.03) in SPRINTHR 2.29 (1.89‐2.76) ACCORD | Worse renal outcome | |||||
| Metanalysis | |||||||||||
| Emdin et al.51 (2015) | 100 334 pts included in trials on BP lowering treatments in T2DM | Associations with 10–mm Hg Lower SBP | Renal failure: NSAlbuminuria: 0.83 CI: 0.79‐0.87, P < 0.01 | No additional renal benefit except for reduction in the incidence of albuminuria | |||||||
| Associations with 10–mm Hg Lower SBP in trials with Mean Achieved SBP in the Active Group ≥130 mm Hg | Renal failure: NSAlbuminuria: RR 0.71, CI: 0.64‐0.79, P < 0.01 | ||||||||||
| Associations with 10–mm Hg Lower SBP in trials with Mean Achieved SBP in the Active Group <130 mm Hg | Renal failure: NSAlbuminuria: RR 0.86, CI: 0.81‐0.90, P < 0.01 | ||||||||||
| Xie et al.52 (2016) | 19 trials (44 989 pts) with more intensive vs less intensiveBP‐lowering treatment; CKD 7% | 133/76 | 140/81 | ESRD: NS | No additional renal benefit | ||||||
| Ettehad et al.31 (2016) | Trials (613 815 pts) on BP lowering treatments | Renal failure: NS | No additional renal benefit | ||||||||
| Tsai et al.26 (2017) | Trials (8127 pts) with more intensive vs less intensive blood pressure‐lowering treatment in ptz with CKD and no diabetes | Difference in mean systolic BP varied from 4 to 13 mm Hg at the end of the trial | Composite renal outcome (doubling of serum creatinine level, 50% reduction in GFR, ESRD): NS | No additional renal benefit | |||||||
BP, blood pressure; CKD is defined as eGFR <60 or albuminuria where available; CI, confidence intervals; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate; ESRD, end stage renal disease; HR, hazard ratio; HT, hypertension; MAP, mean arterial pressure; RR, relative risk; SBP, systolic blood pressure.