Hypertension in chronic kidney disease after the Systolic Blood Pressure Intervention Trial: targets, treatment and current uncertainties

Hypertension is the number one cardiovascular (CV) risk factor, and its treatment represents one of the most important interventions in patients at high risk for CV events. Patients with chronic kidney disease (CKD) are at high CV risk, yet as a group they have been excluded from most major blood pressure (BP)-lowering trials examining CV and mortality end points. The paucity of randomized clinical trial evidence for BP lowering in CKD patients is compounded by the fact that the association between BP levels and clinical outcomes in patients with CKD suggests the presence of a J-curve, which makes extrapolations from general population studies especially difficult. The recent completion of the Systolic Blood Pressure Intervention Trial (SPRINT), which enrolled a large number of patients with mild to moderate CKD, has raised hope for much-needed clarity about the ideal systolic BP target in this patient population. This review discusses the epidemiology of hypertension in CKD and the pathophysiologic underpinnings of the distinct associations between BP levels and clinical outcomes in patients with CKD, and it examines the applicability of the SPRINT results to the general CKD population.