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More intensive BP lowering may prevent ESKD in selected proteinuric patients with CKD

Clinical Question:
Does more intensive control of blood pressure improve outcomes in patients with chronic kidney disease?

Bottom Line:
More intensive control of blood pressure in patients with chronic kidney disease (CKD) and proteinuria may prevent progression of disease and the onset of end-stage kidney disease (ESKD). However, my confidence in this conclusion is tempered by the failure to see this benefit in the better-designed studies, and the failure to see any impact on cardiovascular events or mortality. (LOE = 1a-)

Reference:
Lv J, Ehteshami P, Sarnak MJ, et al. Effects of intensive blood pressure lowering on the progression of chronic kidney disease: a systematic review and meta-analysis. CMAJ 2013;185(11):949-957.  [PMID:23798459]

Study Design:
Meta-analysis (randomized controlled trials)

Funding:
Industry + foundation

Setting:
Outpatient (any)

Synopsis:
The authors of this meta-analysis searched for clinical trials that randomized patients with CKD to more or less intensive blood pressure targets. The targets varied, but intensive control typically sought to achieve a diastolic blood pressure of less than 80 mm Hg or a mean blood pressure of less than 92 mm Hg. They identified 11 randomized controlled trials with 9287 participants. The quality of trials was limited, with most failing to mask patients, 3 not reporting whether analysis was by intention to treat or per protocol, and 4 not describing allocation concealment. Seven studies with a total of 5308 participants found a decrease in the likelihood of a composite outcome of doubling of the serum creatinine level or ESKD (hazard ratio [HR] = 0.82; 95% CI, 0.68 - 0.98) and of the likelihood of ESKD (HR = 0.79; 0.67 - 0.93). However, when patients were stratified by whether they had proteinuria at baseline, only patients with proteinuria had a reduction in the likelihood of ESKD (HR = 0.73; 0.62 - 0.86). The hazard ratio for patients without proteinuria was 1.12 (0.67 - 1.87). The effect was also greater in studies that failed to mask or conceal allocation. For example, in the 3 studies that properly concealed allocation, the hazard ratio was 0.95 (0.79 - 1.13), compared with 0.71 (0.61 - 0.82) in studies where allocation concealment was not clearly described. There was no effect of more intensive blood pressure control on cardiovascular events or mortality. Note that most studies did not include patients with diabetic kidney disease.

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