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Does intensive blood pressure control provide better renoprotection for nondiabetic chronic kidney disease?
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.
Targeting blood pressure below the current standard is not consistently warranted, but may benefit nonblack patients or those with heavy proteinuria.
The optimal blood pressure (BP) target remains debated in nondiabetic patients with chronic kidney disease (CKD).
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.
Searches of PubMed, MEDLINE, Embase, and Cochrane Library for publications up to March 24, 2016.
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.
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, 0.81; 95% CI, 0.64-1.02). Intensive BP control reduced mortality (RR, 0.78; 95% CI, 0.61-0.99) in sensitivity analysis when the study populations were strictly restricted to those without diabetes. 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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Corresponding Author: Hon-Yen Wu, MD, PhD, Department of Internal Medicine, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S Rd, Banciao District, New Taipei City 220, Taiwan (firstname.lastname@example.org).
Accepted for Publication: January 23, 2017.
Correction: This article was corrected on September 18, 2017, for omission of data and errors in the meta-analysis.
Published Online: March 13, 2017. doi:10.1001/jamainternmed.2017.0197
Author Contributions: Drs Wu and Chien had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Wu and Chien contributed equally as corresponding authors to this work.
Study concept and design: Tsai, Wu, Peng, Yang, Hung, Chien.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Tsai, Wu, Tu, Chien.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Tsai, Wu, Yang, Tu.
Obtained funding: Wu, Ko, Hung, Chien.
Administrative, technical, or material support: Chen, Chiu, Hsu, Pai.
Supervision: Wu, Peng, Hung, Chien.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by research grants to Dr Wu from the National Health Research Institutes, Taiwan (NHRI-EX105-10510PC), and the Far Eastern Memorial Hospital, New Taipei City, Taiwan (FEMH-EX105-10510PC).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
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