Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus: secondary analyses of two randomised controlled trials.
Pubmed ID: 29685860
Pubmed Central ID: PMC6071316
Journal: The lancet. Diabetes & endocrinology
Publication Date: 07/01/2018
Affiliation: Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA.
MeSH Terms: Humans, Male, Female, Aged, Middle Aged, Randomized Controlled Trials as Topic, Diabetes Complications, Treatment Outcome, Blood Pressure, Glomerular Filtration Rate, Renal Insufficiency, Chronic, Antihypertensive Agents
Grants: UL1 TR000445, UL1 TR000005, HHSN268200900040C, HHSN268200900046C, HHSN268200900047C, HHSN268200900048C, HHSN268200900049C, P30 GM103337, UL1 TR000433, UL1 TR000439, UL1 TR000002, UL1 TR001064, UL1 TR000064, UL1 TR000075, UL1 RR025752, UL1 RR025771, UL1 TR000093, UL1 TR000003, UL1 TR000050, UL1 TR000073, UL1 RR025755, UL1 TR000105, UL1 RR024134, UL1 RR025764, C06 RR011234, R01 DK091437, R21 DK106574, UL1 TR001427, UL1 TR002240
Authors: Beddhu S, Greene T, Cheung AK, Chertow GM, Whelton PK, Kimmel PL, Cushman WC, Chonchol M, Kramer H, Wei G, Ix JH, Stoddard G, Boucher R
Cite As: Beddhu S, Greene T, Boucher R, Cushman WC, Wei G, Stoddard G, Ix JH, Chonchol M, Kramer H, Cheung AK, Kimmel PL, Whelton PK, Chertow GM. Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus: secondary analyses of two randomised controlled trials. Lancet Diabetes Endocrinol 2018 Jul;6(7):555-563. Epub 2018 Apr 21.
BACKGROUND: Guidelines, including the 2017 American College of Cardiology and American Heart Association blood pressure guideline, recommend tighter control of systolic blood pressure in people with type 2 diabetes. However, it is unclear whether intensive lowering of systolic blood pressure increases the incidence of chronic kidney disease in this population. We aimed to compare the effects of intensive systolic blood pressure control on incident chronic kidney disease in people with and without type 2 diabetes. METHODS: The Systolic Blood Pressure Intervention Trial (SPRINT) tested the effects of a systolic blood pressure goal of less than 120 mm Hg (intensive intervention) versus a goal of less than 140 mm Hg (standard intervention) in people without diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial tested a similar systolic blood pressure intervention in people with type 2 diabetes. Our study is a secondary analysis of limited access datasets from SPRINT and the ACCORD trial obtained from the National Institutes of Health. In participants without chronic kidney disease at baseline (n=4311 in the ACCORD trial; n=6715 in SPRINT), we related systolic blood pressure interventions (intensive vs standard) to incident chronic kidney disease (defined as >30% decrease in estimated glomerular filtration rate [eGFR] to <60 mL/min per 1·73 m<sup>2</sup>). These trials are registered with ClinicalTrials.gov, numbers NCT01206062 (SPRINT) and NCT00000620 (ACCORD trial). FINDINGS: The average difference in systolic blood pressure between intensive and standard interventions was 13·9 mm Hg (95% CI 13·4-14·4) in the ACCORD trial and 15·2 mm Hg (14·8-15·6) in SPRINT. At 3 years, the cumulative incidence of chronic kidney disease in the ACCORD trial was 10·0% (95% CI 8·8-11·4) with the intensive intervention and 4·1% (3·3-5·1) with the standard intervention (absolute risk difference 5·9%, 95% CI 4·3-7·5). Corresponding values in SPRINT were 3·5% (95% CI 2·9-4·2) and 1·0% (0·7-1·4; absolute risk difference 2·5%, 95% CI 1·8-3·2). The absolute risk difference was significantly higher in the ACCORD trial than in SPRINT (p=0·0001 for interaction). INTERPRETATION: Intensive lowering of systolic blood pressure increased the risk of incident chronic kidney disease in people with and without type 2 diabetes. However, the absolute risk of incident chronic kidney disease was higher in people with type 2 diabetes. Our findings suggest the need for vigilance in monitoring kidney function during intensive antihypertensive drug treatment, particularly in adults with diabetes. Long-term studies are needed to understand the clinical implications of antihypertensive treatment-related reductions in eGFR. FUNDING: National Institutes of Health.