Target blood pressure and kidney protection

Abstract

For many years, low on-treatment blood pressure values were widely regarded as necessary to maximise renal protection in individuals with high blood pressure. This notion was generated by several lines of evidence. Findings suggested that low blood pressure values could diminish or eliminate glomerular protein excretion, 1 Mancia G Schumacher H Redon J et al. Blood pressure targets recommended by guidelines and incidence of cardiovascular and renal events in the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET). Circulation. 2011; 124: 1727-1736 Crossref PubMed Scopus (137) Google Scholar which might lead to renal damage. Furthermore, the kidney can autoregulate its blood flow effectively over a wide range of blood pressure values, lessening concerns that low blood pressure might trigger renal underfusion, renal ischaemia, and a J-shaped relation with cardiac events. 2 Mancia G Grassi G Aggressive blood pressure lowering is dangerous: the J-curve. Hypertension. 2014; 63: 29-36 Crossref PubMed Scopus (89) Google Scholar Finally, in clinical studies, a progressive reduction in the glomerular filtration rate was attenuated in patients with intense treatment-induced blood pressure reductions versus less intense lowering of blood pressure, 3 Jafar TH Stark PC Schmid CH et al. Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med. 2003; 139: 244-252 Crossref PubMed Scopus (957) Google Scholar which also seemed to occur in patients with pronounced proteinuria. In the Modification of Diet in Renal Disease study in patients with non-diabetic nephropathy, 4 Peterson JC Adler S Burkart JM et al. Blood pressure control, proteinuria, and the progression of renal disease: the Modification of Diet in Renal Disease Study. Ann Intern Med. 1995; 123: 754-762 Crossref PubMed Scopus (1228) Google Scholar cutting mean arterial pressure to 92 mm Hg rather than 107 mm Hg was associated with a lesser decline in renal function in the subgroup of individuals with urinary protein excretion greater than 3 g/day. Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus: secondary analyses of two randomised controlled trialsIntensive lowering of systolic blood pressure increased the risk of incident chronic kidney disease in people with and without type 2 diabetes. However, the absolute risk of incident chronic kidney disease was higher in people with type 2 diabetes. Our findings suggest the need for vigilance in monitoring kidney function during intensive antihypertensive drug treatment, particularly in adults with diabetes. Long-term studies are needed to understand the clinical implications of antihypertensive treatment-related reductions in eGFR. Full-Text PDF