Study Shows Potential Population-Level Benefits of Intensive BP Targets in Adults With CKD

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Currently, it is unclear if the effects of intensive vs blood pressure (BP) targets shown in clinical trials are generalizable to patients who have chronic kidney disease (CKD) in everyday practice. There may be differences in distribution of cardiovascular risk factors or co-existing conditions. The authors of a study published in JAMA Network Open estimated the outcomes that are associated with treating hypertension to a systolic BP (<120 mm Hg) compared with less than 140 mm Hg in 2 Systolic Blood Pressure Intervention Trial (SPRINT)–eligible clinical populations with CKD.

This comparative effectiveness study was approved by institutional review boards, the VA Palo Alto Health Care System’s Office of Research and Development, and Kaiser Permanente of Southern California (KPSC). The authors noted that the study follows the International Society of Pharmacoeconomics and Outcomes Research reporting guidelines in place for comparative effectiveness research.

The study included data from 3 independent data sources, which included publicly available data from SPRINT (an open-label, nonblinded, randomized clinical trial that enrolled adults without diabetes and with hypertension and elevated cardiovascular risk indicated by the presence of either CKD or other cardiovascular risk factors) and 2 distinct electronic health record databases used to define different target populations of interest (2 clinical populations with CKD and hypertension from the Veterans Health Administration [VHA] and KPSC between January 1, and December 31, 2019).

The outcomes used for this analysis were the same as those identified in SPRINT. The primary end point was a composite of myocardial infarction, acute coronary syndrome, stroke, heart failure, or death from cardiovascular causes, based on adjudication. Secondary end points included all-cause mortality, individual major adverse cardiovascular events, adjudicated dementia and mild cognitive impairment, CKD progression (defined as the composite of a 50% decrease in estimated glomerular filtration rate [eGFR] or development of kidney failure requiring chronic dialysis or kidney transplantation), and individual components of the CKD outcome. The investigators also confirmed patient-reported serious adverse events (AEs), such as hypotension, syncope, bradycardia, electrolytes abnormality, injurious fall, and acute kidney injury.

A total of 85,938 adults with CKD were enrolled from the VHA database and 13,983 from the KPSD database. The mean ages were about 75.7 and 77.4 years, respectively, and most patients from VHA were male (n = 81,628; 95.0%), unlike KPSD (n = 5371; 38.4%).

In addition, compared with 9361 SPRINT participants (mean age: 67.9 years; male: n = 6029; 64.4%), these patients were older, had less prevalent cardiovascular disease, higher albuminuria, and used more statins. The observed associations of intensive vs standard BP control with major cardiovascular events, all-cause death, and AEs were transportable from the trial to the VHA and KPSC populations. Despite this, the trial’s effects on both cognitive and CKD outcomes were not transportable in 1 or both clinical populations, according to the authors.

Further, compared with standard BP treatment, intensive BP treatment was associated with lower absolute risks for major cardiovascular events at 4 years by approximately 5.1% (95% CI, −9.8% to 3.2%) and 3.0% (95% CI, −6.3% to 0.3%) in the VHA and KPSC populations, respectively. There were also higher risks for AEs by about 1.3% (95% CI, −5.5% to 7.7%) in the VHA population and 3.1% (95% CI, −1.5% to 8.3%) in the KPSC population. In the KPSC population, the authors estimated the number needed to treat (NNT) with intensive vs standard BP control over 4 years to prevent 1 cardiovascular event or cardiovascular death was 33, the NNT to prevent 1 all-cause death was 44, and the number needed to cause 1 serious adverse event was 33.

Overall, the authors determined that the reduction in fatal and nonfatal cardiovascular end points and the increased in observed AEs in SPRINT were primarily transportable to trial-eligible CKD populations from clinical practice. They note that this suggests there are benefits of implementing intensive BP targets.

REFERENCE

Kurella Tamura M, Huang M, An J, et al. SPRINT Treatment Among Adults With Chronic Kidney Disease From 2 Large Health Care Systems. JAMA Netw Open. 2025;8(1):e2453458. doi:10.1001/jamanetworkopen.2024.53458