Intensive BP Control Cuts CV Risk Regardless of CKD Status

Intensive blood pressure (BP) lowering reduced the risk of major cardiovascular (CV) events by 15% for every 10-mm Hg reduction in systolic BP (SBP) in adults with and without chronic kidney disease (CKD), according to a systematic review and meta-analysis published in JAMA Cardiology. The strategy increased the risk of sustained declines in estimated glomerular filtration rate (eGFR) but did not increase the risk of kidney failure. These findings have direct implications for pharmacists who titrate antihypertensive regimens and monitor kidney function.¹

Since 2021, the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines have recommended an SBP target of less than 120 mm Hg for individuals with CKD. The study authors note, however, that uncertainty about intensive BP lowering in established CKD, particularly at an eGFR below 30 mL/min/1.73 m², has led to inconsistent targets across guidelines. In practice, pharmacists may see patients with CKD managed to different goals depending on which guideline a clinician follows.^1,2

Updated Analysis Adds 3 Large Trials

The investigators identified 27 randomized clinical trials, including 88,830 participants. These included 3 large trials reported since previous CKD-focused meta-analyses: ESPRIT, BPROAD, and STEP. Results were standardized to each trial's achieved SBP difference.¹

CV Benefit Held in Patients With CKD

Overall, intensive BP lowering reduced CV events per 10 mm Hg lower SBP (relative risk [RR], 0.85; 95% CI, 0.81-0.89). Among patients with CKD, the reduction was 11% (RR, 0.89; 95% CI, 0.81-0.99). That was comparable to the 16% reduction in those without CKD (RR, 0.84; 95% CI, 0.80-0.88; P for heterogeneity = .26).¹

CV events occurred more often in patients with CKD, so the estimated absolute benefit was at least as large in that group: 4.2 vs 2.7 events avoided per 1000 person-years. That makes patients with CKD a high-yield population for pharmacist-led BP optimization. In an exploratory analysis, intensive BP lowering also reduced all-cause mortality (RR, 0.89; 95% CI, 0.83-0.95).¹

eGFR Declines Did Not Translate to Kidney Failure

Intensive BP lowering had no effect on kidney failure (RR, 0.97; 95% CI, 0.84-1.11). The result held when within-trial and posttrial data covering 1331 kidney failure outcomes were combined (RR, 0.93; 95% CI, 0.84-1.02). However, intensive lowering increased the risk of sustained eGFR declines of 30% or greater (RR, 1.42; 95% CI, 1.28-1.58) and 40% or greater (RR, 1.47; 95% CI, 1.30-1.66).¹

What Pharmacists Should Watch

Regimen changes drove much of the kidney signal. In the recent large trials, intensive targets were reached with greater use of diuretics and calcium channel blockers. Use of renin-angiotensin system inhibitors differed only modestly between arms. Diuretic use at study end was 43% vs 15% in ESPRIT and 67% vs 43% in SPRINT.¹

The authors suggest the eGFR declines may reflect hemodynamic responses to the added diuretics. They note that smaller percentage declines are less reliable markers of kidney failure when a treatment causes an acute eGFR dip.^1,3,4

That context can help pharmacists interpret an early eGFR drop after a diuretic is added, but the authors caution that a small harm cannot be excluded. SPRINT reported more acute kidney injury adverse events with intensive treatment (4.4% vs 2.6%). The authors advise careful monitoring of BP, eGFR, and electrolytes when implementing an intensive strategy.^1,3

Counseling matters as well, because other analyses have linked intensive BP lowering to hypotension-related adverse events, including syncope and falls. Measurement technique is another consideration. SPRINT used largely unattended standardized measurements, and ESPRIT used clinician-attended standardized office readings. As a result, readings taken at the pharmacy counter may not map directly onto trial targets.^1,3,4

Limitations

The analysis relied mainly on tabular rather than individual participant data, and uncertainty remains for patients with an eGFR below 30 mL/min/1.73 m². Some participants in the non-CKD analyses may have had undiagnosed CKD. The study was funded by a European Renal Association fellowship program, with no industry funding.¹

The study authors concluded that guidelines should recommend intensive BP lowering in people with and without CKD, with careful kidney function monitoring.¹

REFERENCES

1. Iatridi F, Roddick AJ, Staplin N, et al. Intensive vs standard blood pressure lowering in people with and without chronic kidney disease: a systematic review and meta-analysis. JAMA Cardiol. Published online October 7, 2026. doi:10.1001/jamacardio.2026.4445

2. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int. 2021;99(3S):S1-S87. doi:10.1016/j.kint.2020.11.003

3. Wright JT Jr, Williamson JD, Whelton PK, et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103-2116. doi:10.1056/NEJMoa1511939

4. Liu J, Li Y, Ge J, et al; ESPRIT Collaborative Group. Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial. Lancet. 2024;404(10449):245-255. doi:10.1016/S0140-6736(24)01028-6