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Original Investigation
March 13, 2017

Association of Intensive Blood Pressure Control and Kidney Disease Progression in Nondiabetic Patients With Chronic Kidney DiseaseA Systematic Review and Meta-analysis

Author Affiliations
  • 1Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
  • 2Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
  • 3Department of Marketing and Distribution Management, Oriental Institute of Technology, New Taipei City, Taiwan
  • 4Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
  • 5School of Medicine, National Yang-Ming University, Taipei, Taiwan
  • 6Department of Dermatology, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
  • 7Department of Dermatology, Taipei City Hospital, Taipei, Taiwan
JAMA Intern Med. Published online March 13, 2017. doi:10.1001/jamainternmed.2017.0197
Key Points

Question  Does intensive blood pressure control provide better renoprotection for nondiabetic chronic kidney disease?

Findings  In this systematic review including 9 randomized clinical trials with 8127 patients and a median follow-up of 3.3 years, intensive and standard blood pressure control provided similar effects. However, nonblack patients and those with higher levels of proteinuria showed a trend of lower risk of kidney disease progression with intensive blood pressure–lowering treatments.

Meaning  Targeting blood pressure below the current standard is not consistently warranted, but may benefit nonblack patients or those with heavy proteinuria.

Abstract

Importance  The optimal blood pressure (BP) target remains debated in nondiabetic patients with chronic kidney disease (CKD).

Objective  To compare intensive BP control (<130/80 mm Hg) with standard BP control (<140/90 mm Hg) on major renal outcomes in patients with CKD without diabetes.

Data Sources  Searches of PubMed, MEDLINE, Embase, and Cochrane Library for publications up to March 24, 2016.

Study Selection  Randomized clinical trials that compared an intensive vs a standard BP target in nondiabetic adults with CKD, reporting changes in glomerular filtration rate (GFR), doubling of serum creatinine level, 50% reduction in GFR, end-stage renal disease (ESRD), or all-cause mortality.

Data Extraction and Synthesis  Random-effects meta-analyses for pooling effect measures. Meta-regression and subgroup analyses for exploring heterogeneity.

Main Outcomes and Measures  Differences in annual rate of change in GFR were expressed as mean differences with 95% CIs. Differences in doubling of serum creatinine or 50% reduction in GFR, ESRD, composite renal outcome, and all-cause mortality were expressed as risk ratios (RRs) with 95% CIs.

Results  We identified 9 trials with 8127 patients and a median follow-up of 3.3 years. Compared with standard BP control, intensive BP control did not show a significant difference on the annual rate of change in GFR (mean difference, 0.07; 95% CI, −0.16 to 0.29 mL/min/1.73 m2/y), doubling of serum creatinine level or 50% reduction in GFR (RR, 0.99; 95% CI, 0.76-1.29), ESRD (RR, 0.96; 95% CI, 0.78-1.18), composite renal outcome (RR, 0.99; 95% CI, 0.81-1.21), or all-cause mortality (RR, 0.95; 95% CI, 0.66-1.37). Nonblacks and patients with higher levels of proteinuria showed a trend of lower risk of kidney disease progression with intensive BP control.

Conclusions and Relevance  Targeting BP below the current standard did not provide additional benefit for renal outcomes compared with standard treatment during a follow-up of 3.3 years in patients with CKD without diabetes. However, nonblack patients or those with higher levels of proteinuria might benefit from the intensive BP-lowering treatments.

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