Intensive blood-pressure control in hypertensive chronic kidney disease.
BACKGROUND
In observational studies, the relationship between blood pressure and end-stage renal disease (ESRD) is direct and progressive. The burden of hypertension-related chronic kidney disease and ESRD is especially high among black patients. Yet few trials have tested whether intensive blood-pressure control retards the progression of chronic kidney disease among black patients.


METHODS
We randomly assigned 1094 black patients with hypertensive chronic kidney disease to receive either intensive or standard blood-pressure control. After completing the trial phase, patients were invited to enroll in a cohort phase in which the blood-pressure target was less than 130/80 mm Hg. The primary clinical outcome in the cohort phase was the progression of chronic kidney disease, which was defined as a doubling of the serum creatinine level, a diagnosis of ESRD, or death. Follow-up ranged from 8.8 to 12.2 years.


RESULTS
During the trial phase, the mean blood pressure was 130/78 mm Hg in the intensive-control group and 141/86 mm Hg in the standard-control group. During the cohort phase, corresponding mean blood pressures were 131/78 mm Hg and 134/78 mm Hg. In both phases, there was no significant between-group difference in the risk of the primary outcome (hazard ratio in the intensive-control group, 0.91; P=0.27). However, the effects differed according to the baseline level of proteinuria (P=0.02 for interaction), with a potential benefit in patients with a protein-to-creatinine ratio of more than 0.22 (hazard ratio, 0.73; P=0.01).


CONCLUSIONS
In overall analyses, intensive blood-pressure control had no effect on kidney disease progression. However, there may be differential effects of intensive blood-pressure control in patients with and those without baseline proteinuria. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Center on Minority Health and Health Disparities, and others.)
Appel
Lawrence J
LJ
Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD 21205-2223, USA. lappel@jhmi.edu
Wright
Jackson T
JT
Greene
Tom
T
Agodoa
Lawrence Y
LY
Astor
Brad C
BC
Bakris
George L
GL
Cleveland
William H
WH
Charleston
Jeanne
J
Contreras
Gabriel
G
Faulkner
Marquetta L
ML
Gabbai
Francis B
FB
Gassman
Jennifer J
JJ
Hebert
Lee A
LA
Jamerson
Kenneth A
KA
Kopple
Joel D
JD
Kusek
John W
JW
Lash
James P
JP
Lea
Janice P
JP
Lewis
Julia B
JB
Lipkowitz
Michael S
MS
Massry
Shaul G
SG
Miller
Edgar R
ER
Norris
Keith
K
Phillips
Robert A
RA
Pogue
Velvie A
VA
Randall
Otelio S
OS
Rostand
Stephen G
SG
Smogorzewski
Miroslaw J
MJ
Toto
Robert D
RD
Wang
Xuelei
X
D000328:Adult; D001741:Black or African American; D000368:Aged; D000419:Albuminuria; D047228:Angiotensin II Type 1 Receptor Blockers / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001794:Blood Pressure; D015331:Cohort Studies; D003404:Creatinine / Q000097:blood; D018450:Disease Progression; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000188:drug therapy* / Q000208:ethnology; D007676:Kidney Failure, Chronic / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D051436:Renal Insufficiency, Chronic / Q000188:drug therapy* / Q000208:ethnology* / Q000209:etiology
D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D003404:Creatinine
J Am Soc Nephrol. 2005 Oct;16(10):3027-37
16120823
JAMA. 2001 Jun 6;285(21):2719-28
11386927
J Am Geriatr Soc. 1985 Apr;33(4):278-85
3989190
JAMA. 1997 Apr 23-30;277(16):1293-8
9109467
Ann Intern Med. 1995 Nov 15;123(10):754-62
7574193
Hypertension. 2003 Dec;42(6):1206-52
14656957
Can J Cardiol. 2009 May;25(5):279-86
19417858
N Engl J Med. 2009 Oct 22;361(17):1639-50
19846849
N Engl J Med. 1996 Apr 11;334(15):939-45
8596594
N Engl J Med. 2007 Nov 22;357(21):2189-94
18032770
J Am Soc Nephrol. 2003 Jul;14(7 Suppl 2):S166-72
12819323
JAMA. 2007 Nov 7;298(17):2038-47
17986697
Arch Intern Med. 2008 Apr 28;168(8):832-9
18443258
Hypertension. 2009 Jan;53(1):20-7
19047584
Nephrol Dial Transplant. 2006 May;21(5):1257-62
16421161
Am J Kidney Dis. 2004 May;43(5 Suppl 1):S1-290
15114537
J Am Soc Nephrol. 2006 Oct;17(10):2928-36
16959828
Clin J Am Soc Nephrol. 2009 Apr;4(4):830-7
19339424
J Am Soc Nephrol. 1998 Dec;9(12 Suppl):S24-30
11443765
Blood Press. 2007;16(3):135-232
17846925
Cochrane Database Syst Rev. 2009 Jul 08;(3):CD004349
19588353
J Am Soc Nephrol. 2003 Jul;14(7 Suppl 2):S154-65
12819322
Ann Intern Med. 2005 Mar 1;142(5):342-51
15738453
N Engl J Med. 1994 Mar 31;330(13):877-84
8114857
JAMA. 2002 Nov 20;288(19):2421-31
12435255
Ann Intern Med. 2003 Aug 19;139(4):244-52
12965979
Ann Intern Med. 2001 Jul 17;135(2):73-87
11453706