Jung Hae Hyuk
Department of Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
Electrolyte Blood Press. 2021 Dec;19(2):19-28. doi: 10.5049/EBP.2021.19.2.19. Epub 2021 Dec 23.
The management of high blood pressure (BP) is crucial for improving outcomes in patients with chronic kidney disease (CKD). The updated Kidney Disease: Improving Global Outcomes 2021 BP guideline proposes treating adults with CKD to a target systolic BP (SBP) of <120 mmHg based on the standardized office BP measurement. This suggestion is largely based on the finding of SPRINT (Systolic Blood Pressure Intervention Trial) that targeting an SBP of <120 mmHg versus <140 mmHg is beneficial for cardiovascular and mortality outcomes, regardless of the patient's kidney disease status. However, extended follow-up studies of CKD trials showed that intensive versus usual BP control was associated with a lower risk of kidney failure in patients with, but not in those without, proteinuria. Similarly, a recent population-based study in Korea demonstrated that the optimal on-treatment BP for composite cardiorenal and mortality outcomes was left-shifted in adults with CKD, particularly in those with albuminuria, relative to that in patients without CKD. Moreover, in meta-analyses of randomized trials, more intensive versus standard BP control was associated with a lower risk of all-cause mortality in patients with CKD and albuminuria but not in those without CKD. Meanwhile, a 2020 Cochrane review reported that lower BP targets (≤135/85 mmHg), compared with standard targets (≤140/90 mmHg), resulted in a small reduction in cardiovascular events, an increase in other serious adverse events, and no reduction in total serious adverse events. Lowering SBP to <120 mmHg can potentially increase the risk of treatment-related adverse events beyond the cardioprotective benefits, and standardized BP measurement increases the burden on patients and resources. Thus, targeting a BP of <130/80 mmHg with appropriate office BP measurement can be an option in patients with CKD. The presence of albuminuria would need to be additionally considered to determine individualized BP targets.
高血压（BP）管理对于改善慢性肾脏病（CKD）患者的预后至关重要。最新的《2021年改善全球肾脏病预后组织血压指南》建议，根据标准化诊室血压测量结果，将CKD成人患者的收缩压（SBP）目标值设定为<120 mmHg。这一建议主要基于收缩压干预试验（SPRINT）的结果，即无论患者的肾脏疾病状况如何，将SBP目标值设定为<120 mmHg对比<140 mmHg，对心血管和死亡率结局有益。然而，CKD试验的延长随访研究表明，强化血压控制与常规血压控制相比，在有蛋白尿的CKD患者中与肾衰竭风险降低相关，但在无蛋白尿的患者中并非如此。同样，韩国最近一项基于人群的研究表明，相对于无CKD的患者，CKD成人患者，尤其是有白蛋白尿的患者，复合心肾和死亡率结局的最佳治疗期血压向左偏移。此外，在随机试验的荟萃分析中，强化血压控制与标准血压控制相比，在有CKD和白蛋白尿的患者中与全因死亡率风险降低相关，但在无CKD的患者中并非如此。同时，2020年Cochrane综述报告称，与标准目标值（≤140/90 mmHg）相比，较低的血压目标值（≤135/85 mmHg）可使心血管事件略有减少，其他严重不良事件增加，且总严重不良事件无减少。将SBP降至<120 mmHg可能会在心脏保护益处之外增加治疗相关不良事件的风险，并且标准化血压测量会增加患者负担和资源消耗。因此，对于CKD患者，采用适当的诊室血压测量，将血压目标设定为<130/80 mmHg可能是一种选择。在确定个体化血压目标时，还需要额外考虑是否存在白蛋白尿。
