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

Commentary: Future Directions in Chronic Kidney Disease Care

It has become clear that the rift that has emerged from 2014 with the publication of the SPRINT and its far-reaching recommendations[9] and the JNC-8 guidelines the same year[8] has echoed in the subsequent edicts issued by governing bodies. The ACC/AHA guidelines trend closer to SPRINT guidelines, the ESH/ECC are more conservative and closer to the JNC-8 guidelines.[24] The ISH guidelines similarly adhere to JNC-8 verbiage as well as recommendations,[28] whereas the most recent 2021 KDIGO guidelines are the implementation of the SPRINT trial without reservations.[29,30] The STEP trial- although duplicating some of the positive findings of the SPRINT trial,[20] used a higher SBP threshold 110–130 mmHg for treatment with an improved safety profile- albeit with a statistically significant finding of hypotension.[20]

It is clear that the safety signals of the SPRINT may not be ignored as there are strong physiologic and epidemiological factors that would suggest that hypotension in the elderly is a real menace,[9,12] including from data extracted from SPRINT itself.[9] A way forward may be to risk stratify elderly patients by frailty before deciding whether to choose a highly interventionalist rather than a more 'geriatric appropriate approach.'[31,32] Further, adapting the AHA/ACC[24] and ESH/ECC[27] approach of using CVD to stratify prehypertension and JNC-stage I hypertension may be useful in deciding on the timing of escalating therapy.

The importance of maintaining tighter BP targets for proteinuria/albuminuria patients has remained key,[4] a corollary of this is further studies may point the way to the need for increased interventions in patients with existing kidney or systemic disease (secondary prevention vs. primary prevention).

Finally, the STEP trial may bring an important corollary to our attention, despite the increased risk of hypotension perhaps 110–130 mmHg is a superior SBP target[20] than the <120 mmHg target dictated by SPRINT.[9] It is certainly no approach that is risk-free as the risk of interventions leading to kidney dysfunction, cognitive abnormalities, and falls can be as devastating in the geriatric/high risk/CKD-ESRD population[18] as the risks of MI, hypotension,[17] CVAs, and other neurological and cardiovascular events. The data have not consistently found evidence of benefits with strict BP control of <120 mmHg, across broad groups of patients with CKD, ESRD, and in elderly patients.[11,12,17–19] The right answer will almost certainly be heavily nuanced, subdivided by groups, examine frailty, examine CVD and CVA risk, as well as lean to a more interventionalist model in patients needing secondary prevention. The KDIGO guidelines are a leap forward to the SPRINT guidelines, but perhaps the pendulum needs to swing back to a more homeostatic position.

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