Effects of intensive blood pressure control across the spectrum of renal impairment: a post hoc analysis from ESPRIT

Background Previous trials have demonstrated that intensive blood pressure (BP) control reduces the risk of cardiovascular disease and mortality at the expenses of kidney-related adverse events. Whether the net benefits outweigh the net harms in patients with different KDIGO risk class or vice versa remain unknown. Methods Patients with high cardiovascular risk were randomized to intensive treatment (targeting SBP below 120 mm Hg) or standard treatment (targeting SBP below 140 mm Hg). We categorized participants into low, moderate, and high/very high KDIGO risk according to KDIGO heatmap. Treatment responses were assessed according to KDIGO risk class. The primary outcome of the study was a composite of myocardial infarction, coronary or non-coronary revascularization, hospitalization or emergency room visit for heart failure, stroke, or death from cardiovascular causes. Safety outcomes included kidney outcomes, and other serious adverse events of special interest. Results Among 11,196 (99.5%) participants with classifiable KDIGO risk class at baseline, 7936 (70.9%), 2628 (23.5%), and 632 (5.6%) were low, moderate and high/very high risk, respectively. Higher KDIGO risk was associated with higher risk of primary outcome (moderate risk: HR 1.45, 95% CI: 1.27-1.65; high/very high risk: HR 2.09, 95% CI: 1.72-2.55, with low risk group as reference). Relative benefits of intensive BP control vs standard BP control on primary outcome and cardiovascular mortality were consistent across KDIGO risk class (P interaction = 0.12; P interaction = 0.16). However, in absolute terms, patients with greater KDIGO risk experienced greater risk reductions on primary outcome and cardiovascular mortality (P interaction = 0.047; P interaction =0.028). Risks of safety outcomes with intensive BP control were not enhanced among participants with high KDIGO risk. Conclusions Intensive BP control provides similar relative protection across the spectrum of KDIGO risk class studied, but progressively greater absolute risk reductions as baseline KDIGO risk increases. These data support the use of KDIGO heatmap to inform intensive BP control decisions.