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Assessment of Vascular Function in Patients With Chronic Kidney Disease
Published on: June 16, 2014
Intensive BP Control in Patients with CKD and Risk for Adverse Outcomes
Elaine Ku1,2, Charles E McCulloch2, Lesley A Inker3
1Departments of Medicine and Pediatrics, Divisions of Nephrology, University of California San Francisco, San Francisco, California.
Insights
Intensive blood pressure control may delay kidney failure in advanced CKD stages 4-5, but not stage 3. This analysis of seven trials found no significant overall benefit but suggests a potential advantage for specific patient groups.
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Clinical Trials
Background:
- Current guidelines recommend intensive blood pressure (BP) control for chronic kidney disease (CKD) patients.
- However, trials on intensive BP control often lack representation of patients with advanced CKD or severe albuminuria.
- The precise impact of intensive BP lowering on kidney outcomes in these specific populations remains unclear.
Purpose of the Study:
- To investigate the effect of intensive BP lowering on kidney outcomes, specifically the risk of kidney failure requiring kidney replacement therapy (KRT).
- To analyze pooled data from multiple trials focusing on patients with estimated glomerular filtration rate (eGFR) below 60 ml/min per 1.73 m².
- To explore subgroup effects based on baseline albuminuria and CKD stage (eGFR levels).
Main Methods:
- Pooled individual-level data from seven relevant clinical trials.
- Included patients with eGFR < 60 ml/min per 1.73 m².
- Conducted prespecified subgroup analyses by baseline albuminuria and eGFR (CKD stages 4-5 vs. stage 3).
Main Results:
- Overall, intensive BP control showed a non-significant trend towards reducing kidney outcomes and death.
- A significant interaction was observed between intensive BP control and baseline eGFR (P interaction=0.05).
- Intensive BP control was associated with a 20% lower risk of the primary kidney outcome in patients with CKD GFR stages 4-5, but not in those with stage 3 CKD.
Conclusions:
- Intensive BP control may benefit patients with advanced CKD (stages 4-5) by delaying the need for KRT.
- No significant benefit was observed for patients with stage 3 CKD.
- Findings support the need for further trials targeting BP goals in populations with advanced kidney disease, with no evidence of harm from intensive BP control.
Significance Statement:
Although most guidelines recommend tightly controlling BP in patients with CKD, individuals with advanced kidney disease or severe albuminuria were not well-represented in trials examining the effect of this intervention on kidney outcomes. To examine the effect of intensive BP control on the risk of kidney outcomes in patients with CKD, the authors pooled individual-level data from seven trials. They found that overall, intensive BP control was associated with a 13% lower, but not significant, risk of a kidney outcome. However, the intervention's effect on the kidney outcome differed depending on baseline eGFR. Data from this pooled analysis suggested a benefit of intensive BP control in delaying KRT onset in patients with stages 4-5 CKD, but not necessarily in those with stage 3 CKD.
Background:
The effect of intensive BP lowering (to systolic BP of <120 mm Hg) on the risk of kidney failure requiring KRT remains unclear in patients with advanced CKD. Such patients were not well represented in trials evaluating intensive BP control.
Methods:
To examine the effect of intensive BP lowering on KRT risk-or when not possible, trial-defined kidney outcomes-we pooled individual-level data from seven trials that included patients with eGFR<60 ml/min per 1.73 m 2 . We performed prespecified subgroup analyses to evaluate the effect of intensive BP control by baseline albuminuria and eGFR (CKD stages 4-5 versus stage 3).
Results:
Of 5823 trial participants, 526 developed the kidney outcome and 382 died. Overall, intensive (versus usual) BP control was associated with a lower risk of kidney outcome and death in unadjusted analyses but these findings did not achieve statistical significance. However, the intervention's effect on the kidney outcome differed depending on baseline eGFR ( P interaction=0.05). By intention-to-treat analysis, intensive (versus usual) BP control was associated with a 20% lower risk of the primary kidney outcome in those with CKD GFR stages 4-5, but not in CKD GFR stage 3. There was no interaction between intensive BP control and the severity of albuminuria for kidney outcomes.
Conclusions:
Data from this pooled analysis of seven trials suggest a benefit of intensive BP control in delaying KRT onset in patients with stages 4-5 CKD but not necessarily with stage 3 CKD. These findings suggest no evidence of harm from intensive BP control, but also point to the need for future trials of BP targets focused on populations with advanced kidney disease.
Podcast:
This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_02_27_JASN0000000000000060.mp3.
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