Blood Pressure Targets for Hypertension in People With Chronic Kidney Disease

Is there a benefit to using a lower blood pressure (BP) target of 130/80 mm Hg for hypertension in people with chronic kidney disease (CKD) compared with a higher BP target of 140 to 160/90 to 100 mm Hg?

Having a lower BP target of 130/80 mm Hg for hypertension in people with CKD compared with a higher BP target of 140 to 160/90 to 100 mm Hg does not reduce total mortality, total serious adverse events, total cardiovascular events, total cardiovascular mortality, or progression to end-stage renal disease.¹ (Strength of Recommendation: B, inconsistent or limited-quality patient-oriented evidence.)

The prevalence of CKD is estimated to be 14% in the United States.² Systemic hypertension is the second leading cause of CKD in the United States behind diabetes and is an independent risk factor for adverse cardiovascular events.^1,2 The authors of this Cochrane review aimed to identify the effects of lower vs higher BP targets on morbidity and mortality in people with CKD.¹

The Cochrane review included six randomized controlled trials with a total of 7,348 adult patients. Participants had hypertension and CKD and were randomized to a lower or standard BP target. Criteria for CKD included albuminuria (ie, urine albumin excretion rate ≥ 30 mg per 24 hours or equivalent); decreased glomerular filtration rate (GFR; ie, < 60 mL/min/1.73 m²); or both. In the included trials, the lower BP target ranged from 120 to 130/80 mm Hg and the standard BP targets ranged from 140 to 149/85 to 90 mm Hg. The mean age of participants ranged from 46 to 70 years. The GFR of participants ranged from 32 to 52 mL/min/1.73 m². The mean duration of follow-up was 3.6 years (range = 1–8.6 years).

A lower BP target compared with a standard BP target resulted in little to no difference in total mortality, total serious adverse events, or total cardiovascular events (moderate-certainty evidence).¹ Lower BP targets compared with standard BP targets did not reduce cardiovascular mortality or progression to end-stage renal disease (low-certainty evidence). There was also little difference in the total number of participants who experienced a doubling of their serum creatinine level or at least a 50% reduction in GFR by the end of the study. Only one study evaluated participant withdrawal from adverse effects and found no difference.

The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 guidelines recommend a BP target of 120/80 mm Hg, and the American College of Cardiology/American Heart Association 2017 guidelines recommend a target of 130/80 mm Hg.^3,4 The Eighth Joint National Committee guidelines and the 2023 European Society of Hypertension (ESH) guidelines recommend a BP target less than 140/90 mm Hg and align more with the findings of this Cochrane review.^5,6 The ESH guidelines recommend a BP below 130/80 mm Hg, especially if patients are young, have an albumin-creatinine ratio of 300 mg/g or greater, or have increased cardiovascular risks. Similarly, the 2021 National Institute for Health and Care Excellence (NICE) guidelines recommend a BP below 140/90 mm Hg if the albumin-creatinine ratio is less than 70 mg/mmol and a BP below 130/80 mm Hg if the albumin-creatinine ratio is 70 mg/mmol or greater.⁷ Because representation in this review of people with stage 4 or more advanced CKD or with severe proteinuria was limited, a tailored approach such as the NICE and ESH guidelines could be considered. Further research is needed to refine BP targets by including people with the full range of CKD, including those with different levels of proteinuria and comorbidities, such as diabetes.