NEWS & VIEWS HYPERTENSION
Is it time to reconsider blood pressure guidelines? Anna Burgner and Julia B. Lewis
Burgner, A. & Lewis, J. B. Nat. Rev. Nephrol. advance online publication 23 September 2014; doi:10.1038/nrneph.2014.174
Hypertension is not only a frequent cause of chronic kidney disease (CKD), but also often complicates its management. Hypertension is also associated with an increased risk of stroke and heart disease. The optimal systolic blood pressure (SBP) target in both the general population and in those with CKD is a topic of much debate. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for the management of blood pressure in CKD cur rently recommends targeting a goal blood pressure of ≤140/90 mmHg in patients without albuminuria and ≤130/90 mmHg in patients with albuminuria.1 However, findings from a new, large, observational study of a historical cohort of US veter ans with CKD with and without protein uria do not fully support these guidelines; lower SBP goals were associated with an increase in all-cause mortality in all patients with CKD.2 The KDIGO guideline that recommends a lower blood pressure target for patients with CKD and proteinuria is based partly on an underpowered subgroup analy sis of the Modification of Diet in Renal Disease (MDRD) trial. This analysis dem onstrated a benefit of randomly allocat ing 158 patients with proteinuria >1 g per 24 h at study entry to a lower blood pres sure goal, despite no overall benefit seen in the 840 individuals enrolled in the trial as a whole.3 The KDIGO recommendations are also partly based on follow-up studies of the MDRD and African American Study of Kidney Disease and Hypertension (AASK) trials. These studies identified
benefits in participants who had originally been assigned to the lower mean arterial blood pressure target groups (≤92 mmHg), approximately 7 years after cessation of the trials.4,5 Importantly, neither the AASK nor MDRD trials showed a benefit of lower blood pressure in their well-powered, intention-to-treat analysis of CKD popula tions during the course of the trials.3,6 Of note, increasing evidence now suggests that lower blood pressure goals are associ ated with an increased risk of adverse out comes in patients with CKD, including risk of stroke. The study by Kovesdy et al. 2 provides additional evidence to further suggest potential increased harm with lower blood pressure goals. The researchers studied a historical cohort of 77,765 US veterans with CKD—defined as having an esti mated glomeru lar filtration rate
Is it time to reconsider blood pressure guidelines? Anna Burgner and Julia B. Lewis
Burgner, A. & Lewis, J. B. Nat. Rev. Nephrol. advance online publication 23 September 2014; doi:10.1038/nrneph.2014.174
Hypertension is not only a frequent cause of chronic kidney disease (CKD), but also often complicates its management. Hypertension is also associated with an increased risk of stroke and heart disease. The optimal systolic blood pressure (SBP) target in both the general population and in those with CKD is a topic of much debate. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for the management of blood pressure in CKD cur rently recommends targeting a goal blood pressure of ≤140/90 mmHg in patients without albuminuria and ≤130/90 mmHg in patients with albuminuria.1 However, findings from a new, large, observational study of a historical cohort of US veter ans with CKD with and without protein uria do not fully support these guidelines; lower SBP goals were associated with an increase in all-cause mortality in all patients with CKD.2 The KDIGO guideline that recommends a lower blood pressure target for patients with CKD and proteinuria is based partly on an underpowered subgroup analy sis of the Modification of Diet in Renal Disease (MDRD) trial. This analysis dem onstrated a benefit of randomly allocat ing 158 patients with proteinuria >1 g per 24 h at study entry to a lower blood pres sure goal, despite no overall benefit seen in the 840 individuals enrolled in the trial as a whole.3 The KDIGO recommendations are also partly based on follow-up studies of the MDRD and African American Study of Kidney Disease and Hypertension (AASK) trials. These studies identified
benefits in participants who had originally been assigned to the lower mean arterial blood pressure target groups (≤92 mmHg), approximately 7 years after cessation of the trials.4,5 Importantly, neither the AASK nor MDRD trials showed a benefit of lower blood pressure in their well-powered, intention-to-treat analysis of CKD popula tions during the course of the trials.3,6 Of note, increasing evidence now suggests that lower blood pressure goals are associ ated with an increased risk of adverse out comes in patients with CKD, including risk of stroke. The study by Kovesdy et al. 2 provides additional evidence to further suggest potential increased harm with lower blood pressure goals. The researchers studied a historical cohort of 77,765 US veterans with CKD—defined as having an esti mated glomeru lar filtration rate
