What is the blood pressure (BP) goal for a person with progressive kidney failure?
Although guidelines such as Joint National Committee (JNC) 8 relaxed BP goals compared with prior treatment recommendations, there has been evidence from studies published subsequent to these guidelines supporting a more aggressive approach to BP management.
The Systolic Blood Pressure Intervention Trial (SPRINT) was a prospective randomized controlled trial that was enriched with CKD patients (although without significant proteinuria) that assigned patients to a systolic BP goal of less than 120 mm Hg (intensive treatment) or less than 140 mm Hg (standard treatment).
BP was measured differently from typical office BPs, using a device that can average multiple consecutive readings with the patient resting alone in a room.
A mean of three consecutive BPs was used as the visit BP.
Overall, participants assigned to the intensive treatment group, as compared with those assigned to the standard treatment group, had a 25% lower relative risk (RR) of major cardiovascular events, with consistent results across subgroups defined according to age, sex, race, medical history, and baseline BP. In addition, the intensive treatment group had a 27% lower RR of death from any cause.
SPRINT was the first randomized controlled trial (RCT) to demonstrate a benefit in lower BP goals (i.e., systolic <140). Of note, the method of BP assessment in the trial is rarely used in clinical practice.
In an earlier RCT, the African American Study of Kidney Disease and Hypertension, African Americans with hypertension and CKD were randomly assigned one of two mean arterial pressure goals: 102 to 107 mm Hg or 92 mm Hg or less.
Achieved BP averaged 128/78 mm Hg in the lower BP group and 141/85 mm Hg in the usual BP group.
The mean change in GFR over the 4 years of the study did not differ significantly between arms (–2.21 vs. –1.95 mL/min per 1.73 m 2 per year, in the lower and usual BP arms, respectively; P = .24).
To address BP targets in diabetic patients, the Action to Control Cardiovascular Risk in Diabetes blood pressure (ACCORD BP) trial randomly assigned 4733 patients with type 2 diabetes who had cardiovascular disease or at least two additional risk factors for cardiovascular disease to either intensive therapy (goal systolic BP less than 120 mm Hg) or standard therapy (goal systolic BP less than 140 mm Hg).
There was no significant difference in the annual rate of the primary composite outcome of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes between the intensive versus standard therapy groups. There was an increase in drug side effects, including hypotension (2.4% vs. 1.4%), syncope (2.3% vs. 1.7%), and acute kidney injury (4.1% vs. 2.5%), in the intensive therapy group versus standard therapy group.
Both SPRINT and ACCORD used the same BP targets, with different patient populations (ACCORD was diabetes only and SPRINT used patients at high cardiovascular disease (CVD) risk but excluded diabetes) and had different results. Of note, SPRINT had twice the number of patients as ACCORD did.
Given conflicting data, current treatment goals are systolic <130 and diastolic <80 for CKD with proteinuria.
Kidney Disease: Improving Global Outcomes (KDIGO) currently recommends a goal BP of systolic <140 and diastolic <90 for nonproteinuric CKD patients.
