Association of Intensive Blood Pressure Control and Kidney Disease Progression in Nondiabetic Patients With Chronic Kidney Disease A Systematic Review and Meta-analysis

作者：Tsai Wan Chuan; wu Hon Yen^*; Peng Yu Sen; Yang Ju Yeh; Chen Hung Yuan; Chiu Yen Ling; Hsu Shih Ping; Ko Mei Ju; Pai Mei Fen; Tu Yu Kang; Hung Kuan Yu; Chien Kuo Liong

来源：JAMA Internal Medicine, 2017, 177(6): 792-799.

DOI：10.1001/jamainternmed.2017.0197

IMPORTANCE The optimal blood pressure (BP) target remains debated in nondiabetic patients with chronic kidney disease (CKD).
OBJECTIVE To compare intensive BP control (<130/80mmHg) with standard BP control (<140/90mmHg) on major renal outcomes in patients with CKD without diabetes.
DATA SOURCES Searches of PubMed, MEDLINE, Embase, and Cochrane Library for publications up to March 24, 2016.
STUDY SELECTION Randomized clinical trials that compared an intensive vs a standard BP target in nondiabetic adults with CKD, reporting changes in glomerular filtration rate (GFR), doubling of serum creatinine level, 50% reduction in GFR, end-stage renal disease (ESRD), or all-cause mortality.
DATA EXTRACTION AND SYNTHESIS Random-effects meta-analyses for pooling effect measures. Meta-regression and subgroup analyses for exploring heterogeneity.
MAIN OUTCOMES AND MEASURES Differences in annual rate of change in GFRwere expressed as mean differences with 95% CIs. Differences in doubling of serum creatinine or 50% reduction in GFR, ESRD, composite renal outcome, and all-cause mortality were expressed as risk ratios (RRs) with 95% CIs.
RESULTS We identified 9 trials with 8127 patients and a median follow-up of 3.3 years. Compared with standard BP control, intensive BP control did not show a significant difference on the annual rate of change in GFR (mean difference, 0.07; 95% CI, -0.16 to 0.29 mL/min/1.73m(2)/y), doubling of serum creatinine level or 50% reduction in GFR (RR, 0.99; 95% CI, 0.76-1.29), ESRD (RR, 0.96; 95% CI, 0.78-1.18), composite renal outcome (RR, 0.99; 95% CI, 0.81-1.21), or all-cause mortality (RR, 0.95; 95% CI, 0.66-1.37). Nonblacks and patients with higher levels of proteinuria showed a trend of lower risk of kidney disease progression with intensive BP control.
CONCLUSIONS AND RELEVANCE Targeting BP below the current standard did not provide additional benefit for renal outcomes compared with standard treatment during a follow-up of 3.3 years in patients with CKD without diabetes. However, nonblack patients or those with higher levels of proteinuria might benefit from the intensive BP-lowering treatments.

• 出版日期2017-6