The role of blood pressure control in the prevention of cardiorenal disease in patients with chronic kidney disease

Optimal blood pressure (BP) control has been debated between two schools of thought: standard BP control to a goal of systolic BP (SBP) <140 mmHg and intensive BP control with a goal of <120 mmHg. Currently only three randomized controlled trials (RCTs) have been performed to address this question, which will be included in this review: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group (2010), the Systolic Blood Pressure Intervention Trial (SPRINT; 2015) and the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial, performed in Chinese participants in 2021 [1–3]. Further insights into BP management to prevent cardiovascular disease (CVD) events in patients with chronic kidney disease (CKD) will also be reviewed here. Unfortunately, there is less data from RCTs for determining optimal BP levels to prevent renal disease progression. Only three studies in non-diabetic CKD—SPRINT, the Modification of Diet in Renal Disease (MDRD) study and the African American Study of Kidney Disease and Hypertension (AASK)—and no studies in patients with CKD due to type 2 diabetes mellitus (T2DM) have been performed to investigate this problem and, to date, the ideal management protocol for clinicians is lacking. In this review we will also include investigations from historically important studies focusing on control of BP and its effects in patients with CKD, including the MDRD study (1993), the AASK study (2001) and the Ramipril Efficacy In Nephropathy 2 (REIN-2) study (2005) [4–6]. The study of CKD patients in the SPRINT study [7] also provides an important perspective on the importance of more intensive BP control on cardiovascular events. It is also important to note that despite the same body of evidence from these clinical studies, guideline committees have come up with different recommendations for target BP, further complicating the question of optimal BP targets. This opinion paper is targeted towards NDT readers with an interest in kidney disease in relation to BP goals and cardiovascular outcomes.