Departments of Medicine and Pediatrics, Divisions of Nephrology, University of California San Francisco, San Francisco, California.
Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California.
J Am Soc Nephrol. 2023 Mar 1;34(3):385-393. doi: 10.1681/ASN.0000000000000072. Epub 2023 Jan 17.
Although most guidelines recommend tightly controlling BP in patients with CKD, individuals with advanced kidney disease or severe albuminuria were not well-represented in trials examining the effect of this intervention on kidney outcomes. To examine the effect of intensive BP control on the risk of kidney outcomes in patients with CKD, the authors pooled individual-level data from seven trials. They found that overall, intensive BP control was associated with a 13% lower, but not significant, risk of a kidney outcome. However, the intervention's effect on the kidney outcome differed depending on baseline eGFR. Data from this pooled analysis suggested a benefit of intensive BP control in delaying KRT onset in patients with stages 4-5 CKD, but not necessarily in those with stage 3 CKD.
The effect of intensive BP lowering (to systolic BP of <120 mm Hg) on the risk of kidney failure requiring KRT remains unclear in patients with advanced CKD. Such patients were not well represented in trials evaluating intensive BP control.
To examine the effect of intensive BP lowering on KRT risk-or when not possible, trial-defined kidney outcomes-we pooled individual-level data from seven trials that included patients with eGFR<60 ml/min per 1.73 m 2 . We performed prespecified subgroup analyses to evaluate the effect of intensive BP control by baseline albuminuria and eGFR (CKD stages 4-5 versus stage 3).
Of 5823 trial participants, 526 developed the kidney outcome and 382 died. Overall, intensive (versus usual) BP control was associated with a lower risk of kidney outcome and death in unadjusted analyses but these findings did not achieve statistical significance. However, the intervention's effect on the kidney outcome differed depending on baseline eGFR ( P interaction=0.05). By intention-to-treat analysis, intensive (versus usual) BP control was associated with a 20% lower risk of the primary kidney outcome in those with CKD GFR stages 4-5, but not in CKD GFR stage 3. There was no interaction between intensive BP control and the severity of albuminuria for kidney outcomes.
Data from this pooled analysis of seven trials suggest a benefit of intensive BP control in delaying KRT onset in patients with stages 4-5 CKD but not necessarily with stage 3 CKD. These findings suggest no evidence of harm from intensive BP control, but also point to the need for future trials of BP targets focused on populations with advanced kidney disease.
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虽然大多数指南建议在 CKD 患者中严格控制血压，但在研究干预对肾脏结局的影响时，并未充分纳入晚期肾病或严重白蛋白尿患者。为了研究强化血压控制对 CKD 患者肾脏结局的影响，作者汇总了来自 7 项试验的个体水平数据。他们发现，总体而言，强化血压控制与肾脏结局风险降低 13%相关，但无统计学意义。然而，干预对肾脏结局的影响取决于基线 eGFR。来自这项汇总分析的数据表明，强化血压控制可延迟 4-5 期 CKD 患者开始接受肾脏替代治疗（KRT），但对 3 期 CKD 患者可能并非如此。
强化降压（收缩压<120mmHg）对晚期 CKD 患者发生需要 KRT 的肾衰竭风险的影响仍不清楚。在评估强化血压控制的试验中，这类患者的代表性不足。
为了研究强化降压对 KRT 风险的影响（或者在不可能的情况下，以试验定义的肾脏结局为评估指标），我们汇总了来自 7 项试验的个体水平数据，这些试验纳入了 eGFR<60ml/min/1.73m 2 的患者。我们进行了预先设定的亚组分析，以评估基线白蛋白尿和 eGFR（4-5 期 CKD 与 3 期 CKD）对强化血压控制效果的影响。
在 5823 名试验参与者中，526 人发生了肾脏结局，382 人死亡。总体而言，在未校正分析中，强化（与常规）血压控制与较低的肾脏结局和死亡风险相关，但这些发现无统计学意义。然而，干预对肾脏结局的影响取决于基线 eGFR（P 交互=0.05）。根据意向治疗分析，在 4-5 期 CKD 患者中，强化（与常规）血压控制与原发性肾脏结局风险降低 20%相关，但在 3 期 CKD 患者中则无此关联。强化血压控制与肾脏结局的白蛋白尿严重程度之间无交互作用。
来自这 7 项试验的汇总分析数据表明，强化血压控制可延迟 4-5 期 CKD 患者开始接受 KRT，但对 3 期 CKD 患者可能并非如此。这些发现表明强化血压控制无明显危害，但也表明需要开展针对晚期肾病患者的血压目标的未来试验。
本文包含一个播客，可在 https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_02_27_JASN0000000000000060.mp3 网址上收听。
