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

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.

Figure.. Pooled Estimates Comparing Intensive Blood Pressure Control With Standard Blood Pressure Control on the Study Outcomes

A, Heterogeneity: I² = 0%; τ² = 0; P = .67. B, Heterogeneity: I² = 0%; τ² = 0; P = .78. C, Heterogeneity: I² = 0%; τ² = 0; P = .53. D, Heterogeneity: I² = 0%; τ² = 0; P = .79. E, Heterogeneity: I² = 0%; τ² = 0; P = .66. For study outcomes C and E, Klahr et al reported information from their study A and study B together. GFR indicates glomerular filtration rate; W, weight.