Intensive BP Control Or Not For Those with Diabetes and CKD

Study looks at whether intensive BP control can increase the risk of CKD.

Guidelines, including the 2017 American College of Cardiology and American Heart Association blood pressure guidelines, recommend tighter control of systolic blood pressure in people with type 2 diabetes. However, it is unclear whether intensive lowering of systolic blood pressure increases the incidence of chronic kidney disease in this population. So the goal was to compare the effects of intensive systolic blood pressure control on incident chronic kidney disease in people with and without type 2 diabetes.

The authors investigated whether intensive systolic blood pressure (BP) control affects incident chronic kidney disease (CKD) in patients with and without type 2 diabetes. Results from two trials (ACCORD vs SPRINT) showed the average difference in systolic BP for intensive intervention vs standard intervention as 13.9 mm Hg vs 15.2 mm Hg. Cumulative incidence of CKD at 3 years was 10.0% with intensive intervention and 4.1% with standard intervention vs 3.5% with intensive and 1.0% with standard, respectively. Absolute risk difference was markedly higher in the ACCORD trial (P = .0001).

The Systolic Blood Pressure Intervention Trial (SPRINT) tested the effects of a systolic blood pressure goal of less than 120 mm Hg (intensive intervention) versus a goal of less than 140 mm Hg (standard intervention) in people without diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial tested a similar systolic blood pressure intervention in people with type 2 diabetes. This study is a secondary analysis of limited access datasets from SPRINT and the ACCORD trial obtained from the National Institutes of Health. In participants without chronic kidney disease at baseline (n=4311 in the ACCORD trial; n=6715 in SPRINT), we related systolic blood pressure interventions (intensive vs standard) to incident chronic kidney disease (defined as >30% decrease in estimated glomerular filtration rate [eGFR] to <60 mL/min per 1·73 m2).

The average difference in systolic blood pressure between intensive and standard interventions was 13.9 mm Hg in the ACCORD trial and 15.2 mm Hg in SPRINT. At 3 years, the cumulative incidence of chronic kidney disease in the ACCORD trial was 10.0% with the intensive intervention and 4.1% with the standard intervention (absolute risk difference 5.9%, 95% CI 4.3-7.5). Corresponding values in SPRINT were 3.5% and 1.0%. The absolute risk difference was significantly higher in the ACCORD trial than in SPRINT (p=0·0001 for interaction).

Intensive lowering of systolic blood pressure increased the risk of incident chronic kidney disease in people with and without type 2 diabetes. However, the absolute risk of incident chronic kidney disease was higher in people with type 2 diabetes. The findings suggest the need for better control in monitoring kidney function during intensive antihypertensive drug treatment, particularly in adults with diabetes.

So, the message to walk away with is that intensive lowering of systolic BP had the effect of increasing the risk of CKD in patients whether they had type 2 diabetes or not, but the incident risk of CKD was higher in individuals with type 2 diabetes.

Practice Pearls:

• Intensive BP control for patients with type 2 diabetes can increase the risk of CKD.
• The importance of kidney function monitoring during intensive antihypertensive drug therapy needs to be emphasized.
• More long-term studies are needed to understand the clinical implications of Intensive BP reductions in those with diabetes and EKG.

Diabetes Care 2017 Dec; dc171722. https://doi.org/10.2337/dc17-1722