Association Between More Intensive vs Less Intensive Blood Pressure Lowering and Risk of Mortality in Chronic Kidney Disease Stages 3 to 5: A Systematic Review and Meta-analysis.

Pubmed ID: 28873137

Pubmed Central ID: PMC5704908

Journal: JAMA internal medicine

Publication Date: Oct. 1, 2017

Affiliation: Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California.

MeSH Terms: Humans, Risk Factors, Blood Pressure, Disease Progression, Renal Insufficiency, Chronic, Antihypertensive Agents, Hypertension, Renal

Grants: R01 AG046206, K24 DK110427, R01 DK098234, UL1 TR001409, R01 HL109284

Authors: Howard BV, Cheung AK, Staessen JA, Odden MC, Peralta CA, Ix JH, Malhotra R, Nguyen HA, Benavente O, Mete M, Mant J, Nadkarni GN, Coleman RL, Holman RR, Zanchetti A, Peters R, Beckett N

Cite As: Malhotra R, Nguyen HA, Benavente O, Mete M, Howard BV, Mant J, Odden MC, Peralta CA, Cheung AK, Nadkarni GN, Coleman RL, Holman RR, Zanchetti A, Peters R, Beckett N, Staessen JA, Ix JH. Association Between More Intensive vs Less Intensive Blood Pressure Lowering and Risk of Mortality in Chronic Kidney Disease Stages 3 to 5: A Systematic Review and Meta-analysis. JAMA Intern Med 2017 Oct 1;177(10):1498-1505.

Studies:

Abstract

IMPORTANCE: Trials in patients with hypertension have demonstrated that intensive blood pressure (BP) lowering reduces the risk of cardiovascular disease and all-cause mortality but may increase the risk of chronic kidney disease (CKD) incidence and progression. Whether intensive BP lowering is associated with a mortality benefit in patients with prevalent CKD remains unknown. OBJECTIVES: To conduct a systematic review and meta-analysis of randomized clinical trials (RCTs) to investigate if more intensive compared with less intensive BP control is associated with reduced mortality risk in persons with CKD stages 3 to 5. DATA SOURCES: Ovid MEDLINE, Cochrane Library, EMBASE, PubMed, Science Citation Index, Google Scholar, and clinicaltrials.gov electronic databases. STUDY SELECTION: All RCTs were included that compared 2 defined BP targets (either active BP treatment vs placebo or no treatment, or intensive vs less intensive BP control) and enrolled adults (≥18 years) with CKD stages 3 to 5 (estimated glomerular filtration rate <60 mL/min/1.73 m2) exclusively or that included a CKD subgroup between January 1, 1950, and June 1, 2016. DATA EXTRACTION AND SYNTHESIS: Two of us independently evaluated study quality and extracted characteristics and mortality events among persons with CKD within the intervention phase for each trial. When outcomes within the CKD group had not previously been published, trial investigators were contacted to request data within the CKD subset of their original trials. MAIN OUTCOME AND MEASURE: All-cause mortality during the active treatment phase of each trial. RESULTS: This study identified 30 RCTs that potentially met the inclusion criteria. The CKD subset mortality data were extracted in 18 trials, among which there were 1293 deaths in 15 924 participants with CKD. The mean (SD) baseline systolic BP (SBP) was 148 (16) mm Hg in both the more intensive and less intensive arms. The mean SBP dropped by 16 mm Hg to 132 mm Hg in the more intensive arm and by 8 mm Hg to 140 mm Hg in the less intensive arm. More intensive vs less intensive BP control resulted in 14.0% lower risk of all-cause mortality (odds ratio, 0.86; 95% CI, 0.76-0.97; P = .01), a finding that was without significant heterogeneity and appeared consistent across multiple subgroups. CONCLUSIONS AND RELEVANCE: Randomization to more intensive BP control is associated with lower mortality risk among trial participants with hypertension and CKD. Further studies are required to define absolute BP targets for maximal benefit and minimal harm.