Optimal blood pressure targets in chronic kidney disease

Transcription

1 Optimal blood pressure targets in chronic kidney disease Pr. Michel Burnier Service of Nephrology and Hypertension University Hospital Lausanne Switzerland

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3 Evidence-Based Guideline for the Management Of High Blood Pressure in Adults JAMA. 2014;311(5):

4 BP and risk of CKD in population studies

5 Age-Adjusted Rates of ESRD and Multivariable Risk of ESRD for Each Category of Blood Pressure Kaiser Permanent Number of ESRD in hypertensive patients: 669/99300 = 0.67% Hsu, C.-y. et al. Arch Intern Med 2005;165:

6 Risk for end-stage renal disease (ESRD) in subgroups stratified by sex 125/75 mmhg Hsu, C.-y. et al. Arch Intern Med 2005;165:

7 Risk for end-stage renal disease (ESRD) stratified by the presence or absence of diabetes mellitus Hsu, C.-y. et al. Arch Intern Med 2005;165:

8 Hazard ratio for renal death for usual levels of blood pressure, glucose and BMI n> subjects from Asia/Pacific area Mean follow-up: 6.8 y O'Seaghdha, C. M. et al. Hypertension 2009;54:

9 BP and risk of CKD in the hypertensive population

10 HR for mortality and ESRD according to systolic BP in treated hypertensives Kaiser Permanent, n > Sim et al, JACC, 2014, 64 (6):

11 Standardised effects of a 10 mm Hg reduction in systolic blood pressure stratified by baseline blood pressure Blood pressure strata are baseline BP values Ettehad D et al. Lancet, 2016; Volume 387, Issue 10022, 2016,

12 Standardised effects of a 10 mm Hg reduction in systolic blood pressure stratified by baseline blood pressure Blood pressure strata are baseline BP values Ettehad D et al. Lancet, 2016; Volume 387, Issue 10022, 2016,

13 BP and ESRD in CKD-KEEP cohort (n=16,129; 2.87y follow up) Peralta C, Arch Intern Med 2012; 172:41-47

14 More vs less intensive lowering of BP in CKD patients Tsai et al, JAMA Intern Med. 2017;177(6):

15 Effect of intensive versus less intensive blood pressure lowering on the risk of other major vascular events, renal outcomes, and mortality The mean blood pressure achieved in the intensive treatment group was 133/76 mm Hg, compared with 140/81 mm Hg in the less intensive treatment group. Xie, X, Lancet, Volume 387, Issue 10017, 2016,

16 Clinical trials investigating the impact of a lower BP target in CKD patients Study Name (n) MDRD (840) AASK Trial (1094) Rein-2 Trial (338) Cause of CKD Non-diabetic Hypertensive ND Race White: 85% Black 100% CKD stage 3-4 Follow-up 4y GFR range ND 3-4 4y 3y <70 or <45 Baseline GFR (ml/min) Low target BP MAP<92 MAP<92 <130/80 mmhg Usual target BP MAP<107 MAP< DBP<90 mmhg Endpoint Change in GFR Change in GFR ESRD

17 Conclusions of these 3 clinical trials During the trial phase, there was no evidence for a superiority of the intensive lowering of BP in the prevention of the progression of CKD.

18 Separation in achieved BP levels between the two intervention groups in the SPRINT participants with CKD Alfred K. Cheung et al. JASN doi: /asn

19 Kaplan-Meier curves for pre-specified outcomes in SPRINT participants with CKD. Primary CV outcome All cause death ESKD and pejoration >50% Alfred K. Cheung et al. JASN doi: /asn

20 egfr decline during follow-up in the SPRINT participants with CKD 0.32 ml/min per 1.73 m2 per year 0.47 ml/min per 1.73 m2 per year Alfred K. Cheung et al. JASN doi: /asn

21 Cumulative Incidence of the Composite Renal Outcome, According to Baseline Proteinuria Status Appel LJ et al. N Engl J Med 2010;363:

22 Intensive vs standard BP lowering in RCTs: effect of proteinuria TRIALS ABCD AASK RENAAL IRMA Hou et (NEJM) REIN ACCOMPLISH Flynn and Bakris Curr Hypertens Rep 2011;13:

23 Percentage of participants with masked and sustained hypertension by egfr and urine protein/creatinine ratio categories Paul E. Drawz et al. CJASN 2016;11:

24 High frequency of masked hypertension in patients with CKD Pogue, V. et al. Hypertension 2009;53:20-27

25 Relationships of mortality and morbidity outcome reductions and increase in discontinuations for adverse events to the extent of SBP and DBP reductions Thomopoulos et al, Journal of Hypertension 2016, 34:

26 Primary and Secondary Outcomes and Renal Outcomes in SPRINT. The SPRINT Research Group. N Engl J Med 2015;373:

27 Risks of intensive BP lowering according to SPRINT extrapolated to NHANES III (18 millions people) Adam P. Bress et al. Circulation. 2017;135:

28 Conclusions In patients with diabetic and non-diabetic nephropathy, there is today no evidence that lowering BP below 130/80 mmhg provides any benefits for the patients in terms of renal disease progression. In CKD patients with a proteinuria > 1g/24h there is a weak evidence for a better renal protection with a target at 130/80 mmhg. Therefore, the recommendation to lower BP in CKD patients to values between mmhg systolic and mmhg diastolic seems reasonable both to reduce the CV risk and the risk of ESKD.