How Low Do We Go (in the Post-SPRINT Era)?

      Hypertension is frequently both a cause and complication of CKD. The optimal blood pressure target in CKD has been of hot debate over the decades with little data to inform the goals. Here, we review the data from the Systolic Blood Pressure Intervention Trial (SPRINT), Modification of Diet in Renal Disease (MDRD), African American Study of Kidney Disease and Hypertension (AASK), Ramipril Efficacy in Nephropathy-2 (REIN-2), and Action to Control Cardiovascular Risk in Diabetes (ACCORD) trials to use the available evidence to better inform what blood pressure goal should be recommended in patients with CKD and to answer the question “How low should we go?”.

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      1. Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg.
        JAMA. 1967; 202: 1028-1034
        • Lewis J.B.
        Blood pressure control in chronic kidney disease: is less really more?.
        J Am Soc Nephrol. 2010; 21: 1086-1092
      2. Report of the Joint National Committee on detection, evaluation, and treatment of high blood pressure. A cooperative study.
        JAMA. 1977; 237: 255-261
        • Paul K.
        • Whelton R.M.C.
        • Wilbert S.
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
        J Am Coll Cardiol. 2018; 71: e127-e248
        • Williams B.
        • Mancia G.
        • Spiering W.
        • et al.
        2018 ESC/ESH Guidelines for the management of arterial hypertension.
        Eur Heart J. 2018; 39: 3021-3104
        • Saran R.
        • Robinson B.
        • Abbott K.C.
        • et al.
        US renal data system 2017 annual data report: epidemiology of kidney disease in the United States.
        Am J Kidney Dis. 2018; 71: A7
        • Lindeman R.D.
        • Tobin J.D.
        • Shock N.W.
        Association between blood pressure and the rate of decline in renal function with age.
        Kidney Int. 1984; 26: 861-868
        • Nielsen S.
        • Schmitz A.
        • Rehling M.
        • Mogensen C.E.
        Systolic blood pressure relates to the rate of decline of glomerular filtration rate in type II diabetes.
        Diabetes Care. 1993; 16: 1427-1432
        • Kovesdy C.P.
        • Lu J.L.
        • Molnar M.Z.
        • et al.
        Observational modeling of strict vs conventional blood pressure control in patients with chronic kidney disease.
        JAMA Intern Med. 2014; 174: 1442-1449
        • Kovesdy C.P.
        • Trivedi B.K.
        • Kalantar-Zadeh K.
        • Anderson J.E.
        Association of low blood pressure with increased mortality in patients with moderate to severe chronic kidney disease.
        Nephrol Dial Transplant. 2006; 21: 1257-1262
        • Weiner D.E.
        • Tighiouart H.
        • Levey A.S.
        • et al.
        Lowest systolic blood pressure is associated with stroke in stages 3 to 4 chronic kidney disease.
        J Am Soc Nephrol. 2007; 18: 960-966
        • Berl T.
        • Hunsicker L.G.
        • Lewis J.B.
        • et al.
        Impact of achieved blood pressure on cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial.
        J Am Soc Nephrol. 2005; 16: 2170-2179
        • Klahr S.
        • Levey A.S.
        • Beck G.J.
        • et al.
        The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group.
        N Engl J Med. 1994; 330: 877-884
        • Wright Jr., J.T.
        • Bakris G.
        • Greene T.
        • et al.
        Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial.
        JAMA. 2002; 288: 2421-2431
        • Ruggenenti P.
        • Perna A.
        • Loriga G.
        • et al.
        Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial.
        Lancet. 2005; 365: 939-946
        • Greene T.
        • Bourgoignie J.J.
        • Habwe V.
        • et al.
        Baseline characteristics in the modification of diet in renal disease study.
        J Am Soc Nephrol. 1993; 4: 1221-1236
        • Umanath K.
        • Lewis J.B.
        • Dwyer J.P.
        Optimizing blood pressure control in patients with non-diabetic glomerular disease.
        Adv Chronic Kidney Dis. 2014; 21: 200-204
        • Sarnak M.J.
        • Greene T.
        • Wang X.
        • et al.
        The effect of a lower target blood pressure on the progression of kidney disease: long-term follow-up of the modification of diet in renal disease study.
        Ann Intern Med. 2005; 142: 342-351
        • Appel L.J.
        • Wright Jr., J.T.
        • Greene T.
        • et al.
        Intensive blood-pressure control in hypertensive chronic kidney disease.
        N Engl J Med. 2010; 363: 918-929
        • Cushman W.C.
        • Evans G.W.
        • et al.
        • ACCORD Study Group
        Effects of intensive blood-pressure control in type 2 diabetes mellitus.
        N Engl J Med. 2010; 362: 1575-1585
        • Papademetriou V.
        • Zaheer M.
        • Doumas M.
        • et al.
        Cardiovascular outcomes in action to control cardiovascular risk in diabetes: impact of blood pressure level and presence of kidney disease.
        Am J Nephrol. 2016; 43: 271-280
        • Ambrosius W.T.
        • Sink K.M.
        • Foy C.G.
        • et al.
        The design and rationale of a multicenter clinical trial comparing two strategies for control of systolic blood pressure: the Systolic Blood Pressure Intervention Trial (SPRINT).
        Clin Trials. 2014; 11: 532-546
        • Wright Jr., J.T.
        • Williamson J.D.
        • et al.
        • SPRINT Research Group
        A randomized trial of intensive versus standard blood-pressure control.
        N Engl J Med. 2015; 373: 2103-2116
        • Turnbull F.
        • Blood Pressure Lowering Treatment Trialists C
        Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials.
        Lancet. 2003; 362: 1527-1535
        • Rocco M.V.
        • Sink K.M.
        • Lovato L.C.
        • et al.
        Effects of intensive blood pressure treatment on acute kidney injury events in the systolic blood pressure intervention trial (SPRINT).
        Am J Kidney Dis. 2018; 71: 352-361
        • Obi Y.
        • Kalantar-Zadeh K.
        • Shintani A.
        • Kovesdy C.P.
        • Hamano T.
        Estimated glomerular filtration rate and the risk-benefit profile of intensive blood pressure control amongst nondiabetic patients: a post hoc analysis of a randomized clinical trial.
        J Intern Med. 2018; 283: 314-327
        • Mezue K.
        • Goyal A.
        • Pressman G.S.
        • Matthew R.
        • Horrow J.C.
        • Rangaswami J.
        Blood pressure variability predicts adverse events and cardiovascular outcomes in SPRINT.
        J Clin Hypertens (Greenwich). 2018; 20: 1247-1252
        • Williamson J.D.
        • Pajewski N.M.
        • et al.
        • SPRINT MIND Investigators for the SPRINT Research Group
        Effect of intensive vs standard blood pressure control on probable dementia: A randomized clinical trial.
        JAMA. 2019; 321: 553-561
        • Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group
        KDIGO clinical practice guideline for the management of blood pressure in chronic kidney disease.
        Kidney Int Suppl. 2012; 2: 337-414
        • Verrotti A.
        • Prezioso G.
        • Scattoni R.
        • Chiarelli F.
        Autonomic neuropathy in diabetes mellitus.
        Front Endocrinol (Lausanne). 2014; 5: 205
        • Huang C.
        • Dhruva S.S.
        • Coppi A.C.
        • et al.
        Systolic blood pressure response in SPRINT (Systolic Blood Pressure Intervention Trial) and ACCORD (Action to Control Cardiovascular Risk in Diabetes): a possible explanation for discordant trial results.
        J Am Heart Assoc. 2017; 6: e007509
        • Ninomiya T.
        • Perkovic V.
        • Turnbull F.
        • et al.
        • Blood Pressure Lowering Treatment Trialists C
        Blood pressure lowering and major cardiovascular events in people with and without chronic kidney disease: meta-analysis of randomised controlled trials.
        BMJ. 2013; 347: f5680
        • Sim J.J.
        • Shi J.
        • Kovesdy C.P.
        • Kalantar-Zadeh K.
        • Jacobsen S.J.
        Impact of achieved blood pressures on mortality risk and end-stage renal disease among a large, diverse hypertension population.
        J Am Coll Cardiol. 2014; 64: 588-597
        • Upadhyay A.
        • Earley A.
        • Haynes S.M.
        • Uhlig K.
        Systematic review: blood pressure target in chronic kidney disease and proteinuria as an effect modifier.
        Ann Intern Med. 2011; 154: 541-548
        • Jafar T.H.
        • Stark P.C.
        • Schmid C.H.
        • et al.
        Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis.
        Ann Intern Med. 2003; 139: 244-252
        • Officers A.
        • Coordinators for the ACRGTA, Lipid-Lowering Treatment to Prevent Heart Attack T
        Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).
        JAMA. 2002; 288: 2981-2997
        • Salman I.M.
        Cardiovascular autonomic dysfunction in chronic kidney disease: a comprehensive review.
        Curr Hypertens Rep. 2015; 17: 59
        • Beckett N.S.
        • Peters R.
        • Fletcher A.E.
        • et al.
        Treatment of hypertension in patients 80 years of age or older.
        N Engl J Med. 2008; 358: 1887-1898
        • Benetos A.
        • Labat C.
        • Rossignol P.
        • et al.
        Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in older nursing home residents: the PARTAGE study.
        JAMA Intern Med. 2015; 175: 989-995
        • White W.B.
        • Anwar Y.A.
        Evaluation of the overall efficacy of the Omron office digital blood pressure HEM-907 monitor in adults.
        Blood Press Monit. 2001; 6: 107-110
        • El Assaad M.A.
        • Topouchian J.A.
        • Darne B.M.
        • Asmar R.G.
        Validation of the Omron HEM-907 device for blood pressure measurement.
        Blood Press Monit. 2002; 7: 237-241
        • Omboni S.
        • Riva I.
        • Giglio A.
        • Caldara G.
        • Groppelli A.
        • Parati G.
        Validation of the Omron M5-I, R5-I and HEM-907 automated blood pressure monitors in elderly individuals according to the International Protocol of the European Society of Hypertension.
        Blood Press Monit. 2007; 12: 233-242
        • Semret M.
        • Zidehsarai M.
        • Agarwal R.
        Accuracy of oscillometric blood pressure monitoring with concurrent auscultatory blood pressure in hemodialysis patients.
        Blood Press Monit. 2005; 10: 249-255
        • Cohen J.B.
        • Wong T.C.
        • Alpert B.S.
        • Townsend R.R.
        Assessing the accuracy of the OMRON HEM-907XL oscillometric blood pressure measurement device in patients with nondialytic chronic kidney disease.
        J Clin Hypertens (Greenwich). 2017; 19: 296-302
        • Edwards C.
        • Hiremath S.
        • Gupta A.
        • McCormick B.B.
        • Ruzicka M.
        BpTRUth: do automated blood pressure monitors outperform mercury?.
        J Am Soc Hypertens. 2013; 7: 448-453
        • Johnson K.C.
        • Whelton P.K.
        • Cushman W.C.
        • et al.
        Blood pressure measurement in SPRINT (Systolic Blood Pressure Intervention Trial).
        Hypertension. 2018; 71: 848-857
        • Nerenberg K.A.
        • Zarnke K.B.
        • Leung A.A.
        • et al.
        Hypertension Canada's 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children.
        Can J Cardiol. 2018; 34: 506-525