Intensive BP control cuts CV events, even in CKD

Clinical takeaway: Consider intensive blood pressure lowering in appropriate patients with or without CKD to reduce cardiovascular risk, while monitoring kidney function for expected declines in eGFR.

Optimal BP targets in chronic kidney disease (CKD) remain debated because intensive treatment can lower eGFR and has raised concerns about accelerating kidney disease. New large trials have expanded the evidence base, prompting a fresh look at the balance between cardiovascular benefit and renal risk.

In a systematic review and meta-analysis published in JAMA Cardiology, investigators pooled data from 27 randomized trials involving 88,830 adults and compared intensive versus standard BP-lowering strategies. Achieved systolic BP differences averaged about 11 mm Hg between treatment groups.

Across the studies, every 10-mm Hg reduction in systolic BP was associated with a 15% lower risk of major cardiovascular events. Benefits were consistent regardless of CKD status, with cardiovascular event risk reduced by 11% among participants with CKD and 16% among those without CKD. Because baseline cardiovascular risk was higher in CKD populations, the absolute benefit was at least as large, preventing an estimated 4.3 cardiovascular events per 1,000 person-years in CKD versus 2.7 per 1,000 person-years in those without CKD.

No increase in kidney failure was detected, including analyses incorporating longer-term follow-up. However, per 10-mm Hg lower systolic BP, intensive treatment increased the risk of sustained eGFR declines of at least 30% and 40% by 42% and 47%, respectively.

The authors suggested these declines may partly reflect changes in kidney blood flow rather than progressive damage, but a small increase in kidney failure risk could not be excluded. Evidence also remains limited for patients with an eGFR below 30 mL/min/1.73 m².

“These data should encourage clinical guidelines to recommend intensive BP lowering in patients with and without CKD to reduce cardiovascular risk and encourage clinicians to implement such regimens with careful kidney function monitoring.”

Source: Iatridi F, et al. (2026 Oct 7) JAMA Cardiol. Intensive vs Standard Blood Pressure Lowering in People With and Without Chronic Kidney Disease: A Systematic Review and Meta-Analysis