Key result
Intensive SBP target <120 mmHg linked to greater kidney function decline vs <130 mmHg.
Why the study?
Although some guidelines recommend a target SBP < 130 or even < 120 mmHg, it is unclear whether such aggressive treatment favorably affects hypertension-related decline of CKD, which has rarely been counted as an important incident endpoint in essential hypertension RCTs.
Does aggressive systolic blood pressure lowering (<120 mmHg or <130 mmHg) reduce chronic kidney disease progression and cardiovascular outcomes in middle-aged and older patients with essential hypertension?
Does aggressive systolic blood pressure lowering (<120 mmHg or <130 mmHg) reduce chronic kidney disease progression and cardiovascular outcomes in middle-aged and older patients with essential hypertension?
This review demonstrates that while targeting systolic blood pressure <120 mmHg consistently increases the risk of kidney function decline in hypertensive patients, a moderate target of <130 mmHg provides cardiovascular protection without adverse renal outcomes.
Answers are grounded in this paper and cite their sources.
May warrant caution with <120 mmHg targets to limit renal decline; challenges KDIGO recommendations and leaves optimal BP goals unresolved.
Chronic kidney disease (CKD) has almost never been counted as an important incident endpoint in randomized clinical trials (RCTs) in the prevention of complications and outcomes in essential hypertension but rather included in broader safety assessments. Although target systolic blood pressure (SBP) < 130 and even < 120 mmHg is recommended by some guidelines, it is unclear whether such aggressive treatment has a favorable effect on hypertension-related decline of CKD. During the past two decades several RCTs have been performed with patients randomized to more aggressive SBP target vs. SBP target closer to standard treatment. Several large RCTs have targeted and/or otherwise achieved SBP as low as 120 mmHg or maybe even lower in fractions of middle-aged and older high risk essential hypertensive people with major worsening of kidney function. However, other RCTs showed neutral effects or even reduction in kidney endpoints with achieved SBP below 130 mmHg and possible benefit in preventing cardiovascular outcomes though inclusion of soft endpoints in some trials diluted the cardiovascular message. Intensive BP lowering is associated with greater declines in kidney function in all major RCTs investigating target SBP < 120 mmHg. The long-term clinical significance of these changes must be interpreted alongside possible cardiovascular risks. Hence, one should aim at a SBP target < 130 mmHg in middle-aged and older hypertensive patients if the treatment is otherwise well tolerated. The benefits of low SBP targets in patients who develop CKD should be reassessed in the context of new available treatments providing kidney protection such as SGLT2-inhibitors, aldosterone antagonists and GLP1-agonists.
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Kjeldsen et al. (2026) conducted a review in Essential hypertension. Intensive systolic blood pressure lowering (target SBP < 120 mmHg or < 130 mmHg) vs. Standard systolic blood pressure target (< 140 mmHg or routine care) was evaluated on Chronic kidney disease progression and worsening of kidney function.
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