On-treatment blood pressure and long-term outcomes in chronic kidney disease

The treatment blood pressure (BP) target in chronic kidney disease (CKD) remains unclear, and whether the benefit of intensive BP-lowering is comparable between CKD and non-CKD patients is debated.

Using the Korean National Health Information Database, 359 492 CKD patients who had received antihypertensives regularly were identified from 12.1 million participants of nationwide health screening. The composite risk of major cardiovascular events, kidney failure and all-cause mortality was assessed according to time-averaged, on-treatment systolic BP.

Over a 9-year follow-up, the composite outcome was noted in 18.4% of 239 700 participants with eGFR <60 mL/min/1.73 m2 and 18.9% of 155 004 with dipstick albuminuria. The thresholds of systolic BP, above which the composite risk increased significantly, in the reduced eGFR and the proteinuric population were 135 mmHg and 125 mmHg, respectively. For all-cause mortality, the respective thresholds were 145 mmHg and 135 mmHg. When comparing the composite risk between propensity score-matched groups, the hazard ratios of on-treatment BP of systolic 135-144 mmHg (reference, 115-124 mmHg) in the reduced eGFR and non-CKD pairs were 1.18 and 0.98, respectively (P = 0.13 for interaction), and those in the proteinuria and non-CKD pairs were 1.30 and 1.01, respectively (P = 0.003 for interaction).

The findings support the recommendation that, based on office BP, the systolic target in CKD with proteinuria is ≤130 mmHg, and the target in CKD with no proteinuria is ≤140 mmHg. The benefit of intensive BP-lowering may be greater in CKD patients, particularly those with proteinuria, than in their non-CKD counterparts.