Strict BP Control in CKD: Hidden Benefits?

Jeffrey S. Berns, MD


July 08, 2015

Editorial Collaboration

Medscape &

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Hello. I am Jeffrey Berns, editor-in-chief of Medscape Nephrology.

Back when I was a renal fellow, the late Dr Norman Siegel was one of my attending physicians. He was an outstanding pediatric nephrologist and teacher. I remember him telling me on more than one occasion that I needed a little more patience, that sometimes patients would just get better if I was a little bit more patient. My wife would probably say that I should have taken his advice a little bit better.

Nonetheless, I thought of Norman while reading a recent study in Kidney International by Elaine Ku and colleagues,[1] from the University of California, San Francisco.

They did a long-term follow-up of the Modification of Diet in Renal Disease (MDRD) study, which was conducted between 1989 and 1993—quite a long time ago. These investigators took a relatively novel approach by extending the follow-up of participants in the MDRD study to 2010.

The MDRD study included patients who had glomerular filtration rates between 13 and 55 mL/min/1.73 m2. The study compared strict blood pressure control vs usual blood pressure control, varying the definition of blood pressure control by age. For those aged 61 years or younger, the "strict" blood pressure control goal was a mean arterial pressure (MAP) of 92 mm Hg or less (which corresponds to a blood pressure of about 125/75 mm Hg). The "usual care" goal was a MAP of ≤ 107 mm Hg, correlating roughly to 140/90 mm Hg. The targets were a little bit higher in patients aged 61 years or older.

During the initial study, no difference was found in progression to end-stage renal disease (ESRD) or development of ESRD in the two blood pressure target groups. In the follow-up study, investigators looked at the all-cause mortality subsequent to closure of the MDRD study and also at some comorbidity data from the [Centers for Medicare & Medicaid Services ESRD] form 2728.

Importantly, they found, at a median follow-up of 19 years, that the risk for death after the development of ESRD was about 30% lower in those who were randomized to the stricter blood pressure control group. The risk for death was 6.1 vs 4.1 per 100 patient-years. This is statistically significant, having a P value of .003.

This is quite a significant finding. The curves separated over an extended period of time, requiring a lot of patience. This was a long-term follow-up study, and maybe it should make us reconsider blood pressure targets in patients with chronic kidney disease (CKD). Recently we have been talking about moving blood pressure targets up to the 140/90 mm Hg range or close to that. There was also more heart failure and coronary artery disease in the ESRD patients who were randomized to the usual blood pressure target.

This is not going to change clinical practice guidelines, but it should give us pause and make us think about the fact that we may have made decisions too soon about blood pressure goals in patients with CKD. Maybe we need to reexamine the targets and move them to a range of 125/75 mm Hg for younger patients and 135/80 mm Hg for older patients. This may not reduce the development of ESRD, but it may substantially and significantly reduce mortality down the road, at least among those who do develop ESRD.

This is a very interesting paper and well worth reading and thinking about. Hopefully this will be considered for future clinical practice guidelines that are looking at blood pressure control targets.

Thank you for listening. This is Jeffrey Berns, editor-in-chief of Medscape Nephrology.


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