This Cochrane systematic review examined whether intensive blood pressure (BP) targets provide additional clinical benefit compared with standard BP targets in adults with both hypertension and chronic kidney disease (CKD). While BP lowering is known to improve outcomes in hypertension, the optimal target in CKD remains uncertain and controversial.
The review included six randomized controlled trials involving 7,348 adults with CKD and hypertension, with follow-up ranging from 1 to 8 years. Intensive BP targets were generally defined as ≤130/80 mmHg, compared with standard targets ranging from 140–160/90–100 mmHg. Trials were conducted across the USA, Canada, Europe, the Americas, and Southeast Asia, with mixed public and private funding.
Overall, the evidence suggests that lower BP targets probably provide little to no additional benefit over standard targets for major clinical outcomes. Intensive BP control did not reduce all-cause mortality, serious adverse events, or major cardiovascular outcomes such as myocardial infarction or stroke. Lower targets may also make little to no difference to cardiovascular mortality or progression of kidney disease. Importantly, data on harms were limited, as serious adverse events were poorly and inconsistently reported across trials.
Several methodological limitations affect confidence in the findings. All studies were open-label, meaning both clinicians and participants were aware of treatment allocation, which may have influenced management and reporting. Blood pressure was measured exclusively in clinic settings, limiting applicability to home or ambulatory BP monitoring. In addition, the relatively small number of trials and events reduced statistical power to detect modest but clinically relevant differences.
Clinical implication: For adults with CKD and hypertension, targeting BP below standard levels does not clearly improve survival, cardiovascular outcomes, or kidney disease progression. Clinicians should individualise BP targets, balancing potential benefits against treatment burden, adverse effects, and patient preference, rather than universally pursuing intensive BP lowering.
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