Reconciling Systolic Blood Pressure Intervention Trial With Eighth Joint National Commission

A Nuanced View of Optimal Hypertension Control in the Chronic Kidney Disease Population

Ekamol Tantisattamo; Anum Hamiduzzaman; Peter Sohn; Rebecca Ahdoot; Ramy M. Hanna

Disclosures

Curr Opin Nephrol Hypertens. 2022;31(1):57-62. 

In This Article

Sprint Trial

Historically, the association between tight BP control and potential adverse events among the CKD population had been investigated. A large cohort study of 651,749 US veterans with CKD examined the association of 96 categories of possible combinations of SBP and DBP from lowest (<80/< 40 mm Hg) to highest (>210/> 120 mm Hg), in 10-mm Hg increments with all-cause mortality. SBP of 130–159 mm Hg combined with DBP of 70–89 mmHg was associated with the lowest adjusted all-cause mortality. The highest mortality was observed among patients with very high or very low in both SBP and DBP concomitantly.[17] Another large cohort study including 77,765 US veterans with estimated GFR (eGFR) 60 mL/min/1.73 m2 and uncontrolled hypertension defined as receiving ≥1 additional antihypertensive medications with evidence of a decrease in SBP revealed that SBP < 120 mmHg was associated with a significantly greater all-cause mortality compared to SBP of 120–139 mmHg after adjustment for propensity scores.[18] Extending the diversity of the study population, a retrospective cohort study examined the clinical outcomes including all-cause mortality and end-stage kidney disease (ESKD) among 398,419 treated hypertensive patients in the Kaiser Permanente Southern California health system. There was a J-shaped association between SBP and DBP and the composite of mortality and ESKD with the lowest outcomes being in SBP and DBP of 130–139 and 60–79 mmHg, respectively. BP with the lowest outcomes was even lower in diabetes with SBP and DBP of 131 and 69 mmHg, respectively, whereas it was higher in elderly ≥70 years old with SBP and DBP of 140 and 70 mmHg.[19]

The SPRINT trial completed in 2014, aimed to move the therapeutic needle toward intervention to decrease the risks of cerebrovascular and cardiovascular events in nondiabetic patients with increased cardiovascular risks. The SPRINT trial arms proposed to control BP < 120 mmHg versus the more traditional control guideline of <140 mmHg.[9] The study was profoundly positive showing a decrease in CVA, and myocardial infarctions resulting in the study being stopped 6 months early.[9] The recommendations of the SPRINT trial were fairly generalized (not nuanced to subgroups), a drop from 2.19% absolute risk to 1.65% absolute risk of CVA and MI was noted.[9] There was, however, a finding of increased risk of 30% decline in eGFR in the more intensive group compared to standard treatment group among patients without baseline CKD (72% of the study population); whereas, all renal outcomes including 50% reduction of eGFR, long-term dialysis, incident albuminuria, and these composite outcomes were not different between two groups who had baseline CKD. Although around 28% of the study population were >75 years old, risks of falls and neurological issues were greater in the intensive arm.[9] A post hoc analysis of the SPRINT in patients with eGFR > 20 ml/min/1.73 m2 demonstrated that patients with lower eGFR had lower benefits from intensive BP control. In addition, among patients with moderate to advanced CKD (eGFR < 45 ml/min/1.73 m2), there was no difference in cardiovascular outcomes, but higher acute kidney injury (AKI) in the intensive group compared to the standard group.[11] Therefore, applying tight BP control in elderly hypertensive patients may convey further risks. These were labeled as a higher rate of 'adverse events'.[9] Thus, while an exciting positive study, these adverse events were not given as much weight as the reductions in cardiovascular and cerebrovascular events observed in the trial.[9] The guidelines were written by the SPRINT authors as supporting a blanket statement of universal SBP reduction to <120 mmHg for all patients.[9]

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