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Assessment of Vascular Function in Patients With Chronic Kidney Disease
Published on: June 16, 2014
Systematic review: blood pressure target in chronic kidney disease and proteinuria as an effect modifier
Ashish Upadhyay1, Amy Earley, Shana M Haynes
1Tufts University School of Medicine, Boston, MA, USA.
Insights
Lowering blood pressure targets below 130/80 mm Hg did not show clear benefits for chronic kidney disease (CKD) patients. Further research is needed to determine if lower targets benefit those with significant proteinuria.
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Clinical Trials
Background:
- The optimal blood pressure target for patients with chronic kidney disease (CKD) remains uncertain.
- Existing research has not definitively established the benefits of lower versus higher blood pressure targets in this population.
Purpose of the Study:
- To systematically review randomized controlled trials comparing lower versus higher blood pressure targets in adult CKD patients.
- To investigate the role of proteinuria as a potential effect modifier in response to different blood pressure targets.
Main Methods:
- A comprehensive search of MEDLINE and the Cochrane Central Register of Controlled Trials (July 2001-January 2011) was conducted.
- Included trials involved adults with CKD, >50 participants/group, ≥1-year follow-up, and assessed outcomes like death, kidney failure, and cardiovascular events.
- Data extraction focused on study design, interventions, outcomes, and quality, with specific attention to proteinuria subgroups.
Main Results:
- Three trials with 2272 participants were analyzed.
- No significant benefit was found for a blood pressure target <125/75 to 130/80 mm Hg compared to <140/90 mm Hg overall.
- Lower-quality evidence suggested potential benefits of lower targets in patients with proteinuria >300-1000 mg/d, who required more medications and experienced more adverse events.
Conclusions:
- Current evidence is inconclusive regarding the superiority of a <130/80 mm Hg target over <140/90 mm Hg for CKD patients.
- The study did not include patients with diabetes, and trial durations may have been insufficient to detect differences in hard clinical outcomes.
- Further investigation is warranted to clarify the benefits of lower blood pressure targets in CKD patients with significant proteinuria.
Background:
The optimal blood pressure target in patients with chronic kidney disease (CKD) is unclear.
Purpose:
To summarize trials comparing lower versus higher blood pressure targets in adult patients with CKD and focus on proteinuria as an effect modifier.
Data Sources:
MEDLINE and the Cochrane Central Register of Controlled Trials (July 2001 through January 2011) were searched for reports from randomized, controlled trials with no language restriction.
Study Selection:
Authors screened abstracts to identify reports from trials comparing blood pressure targets in adults with CKD that had more than 50 participants per group; at least 1-year follow-up; and outcomes of death, kidney failure, cardiovascular events, change in kidney function, number of antihypertensive agents, and adverse events.
Data Extraction:
Reviewers extracted data on study design, methods, sample characteristics, interventions, comparators, outcomes, number of medications, and adverse events and rated study quality and quality of analyses for proteinuria subgroups.
Data Synthesis:
Three trials with a total of 2272 participants were included. Overall, trials did not show that a blood pressure target of less than 125/75 to 130/80 mm Hg is more beneficial than a target of less than 140/90 mm Hg. Lower-quality evidence suggests that a low target may be beneficial in subgroups with proteinuria greater than 300 to 1000 mg/d. Participants in the low target groups needed more antihypertensive medications and had a slightly higher rate of adverse events.
Limitations:
No study included patients with diabetes. Trial duration may have been too short to detect differences in clinically important outcomes, such as death and kidney failure. Ascertainment and reporting of adverse events was not uniform.
Conclusion:
Available evidence is inconclusive but does not prove that a blood pressure target of less than 130/80 mm Hg improves clinical outcomes more than a target of less than 140/90 mm Hg in adults with CKD. Whether a lower target benefits patients with proteinuria greater than 300 to 1000 mg/d requires further study.
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