Intensive versus Less-Intensive Blood Pressure Control in Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Clinical Trials.

Introduction: High blood pressure accelerates chronic kidney disease (CKD) progression, but the optimal intensity of blood pressure control in this population remains unclear. We aimed to determine whether intensive blood pressure control, compared to less-intensive control, improves clinical outcomes in individuals with CKD.

Methods: A comprehensive search of PubMed, Embase, Scopus, and the Cochrane Library was conducted through December 2024. Randomized controlled trials comparing intensive versus standard blood pressure targets in patients with CKD stage 3 or higher were included. Eligible studies reported all-cause mortality and at least one cardiovascular or renal outcome. Risk of bias was assessed using the Cochrane Risk of Bias tool. A random-effects model was used to pool risk ratios (RRs) with 95% confidence intervals (CIs). Subgroup analyses were performed based on the baseline systolic blood pressure, inclusion of diabetic patients versus exclusion, and baseline glomerular filtration rate (GFR).

Results: Eleven randomized controlled trials with 8,740 participants were included. Intensive blood pressure control did not significantly reduce all-cause mortality (6.4% vs. 6.9%; RR, 0.91 [95% CI 0.73-1.13]; p = 0.32), cardiovascular mortality (RR, 0.89 [95% CI 0.69-1.15]; p = 0.3), major adverse cardiovascular events (RR, 0.91 [95% CI 0.69-1.20]; p = 0.27), decline in kidney function (RR, 0.86 [95% CI 0.59-1.25]; p = 0.34), or progression to end-stage kidney disease (RR, 1.00 [95% CI 0.81-1.23]; p = 0.99).

Conclusions: Intensive BP control did not improve overall mortality or renal outcomes in CKD patients. Further large, long-term studies are warranted.