SP 05-2 WHAT SHOULD BE THE TARGET BLOOD PRESSURE FOR CKD WITH OVERT PROTEINURIA?

Hypertension and Chronic Kidney Disease are both common. The vast majority of patients with chronic kidney disease (CKD) have hypertension. Hypertension can be both a cause and a result of CKD. Many patients with CKD, both diabetic and non-diabetic have overt proteinuria (>300 mg/day). Patients with proteinuria are at higher risk for progression of kidney disease and for atherosclerosis. Because patients with CKD are often excluded from hypertension trials with hard outcomes, there has been until recently less data than ideal to consider in making decisions. The goal of antihypertensive treatment in patients with CKD and proteinuria is to reduce the risk of progression of renal disease and to prevent cardiovascular disease. Hypertension can be treated with a variety of antihypertensive agents. Some classes have been demonstrated to be superior to other classes in preventing progression of renal disease (ace Inhibitors, angiotensin receptor antagonists, and non-dihydropyridine calcium antagonists). Because of a paucity of data, ideal goal blood pressure for patients with CKD and proteinuria has been uncertain for a number of years. Various groups recommended goal SBP ranging from 120 mmHg to 140 mmHg. The Systolic Blood Pressure Intervention Trial (SPRINT) completed in the last year provided new data and new insight for goal blood pressure in patients with CKD (with and without proteinuria). In SPRINT, 28% of the participants had CKD stage 3 or 4. In these patients, those treated to a lower goal SBP (120 mmHg), cardiovascular outcomes were reduced compared to those with a goal of 140 mmHg. In these patients, renal function remained stable with the more aggressive goal. (In patients with normal renal function at baseline, some participants experienced a small reduction in renal function.) The achieved SBP in SPRINT was just over 121 mmHg. And importantly, automated office blood pressure averaging three measurements with no person present in the room when measurements were obtained was used in SPRINT. This correlates to roughly 130 mmHg by standard office blood pressure measurements. Based on this information from SPRINT, a SBP goal of 130 mmHg for patients with CKD and proteinuria seems reasonable. Older patients in particular will benefit from slow, incremental lowering of blood pressure to that range to minimize adverse effects.