Blood pressure lowering treatment for prevention of cardiovascular diseases in people with and without chronic kidney disease: an individual participant-level data meta-analysis

Abstract Background While the deleterious impact of hypertension on both cardiovascular and renal outcomes is well documented, a critical knowledge gap remains regarding whether pharmacological blood pressure-lowering treatment yields differential benefits in cardiovascular risk reduction across the spectrum of chronic kidney disease (CKD). Purpose This study aimed to assess the effect of a fixed amount of systolic blood pressure reduction on major cardiovascular outcomes in individuals with and without CKD. It also examined whether the treatment effect in individuals with CKD varies by CKD progression stages and systolic blood pressure categories at baseline. Methods A one-stage individual participant-level meta-analysis was conducted using the Blood Pressure Lowering Treatment Trialists’ Collaboration (BPLTTC) dataset. The intervention group was defined as follows: the active treatment arm in placebo-controlled trials, the group with the greater systolic blood pressure reduction in head-to-head trials, and the intensive treatment group in trials comparing different blood pressure-lowering strategies. The primary outcome was a composite of fatal and non-fatal stroke, myocardial infarction, ischaemic heart disease, and heart failure requiring hospitalisation or resulting in death. Cox proportional hazard models, stratified by trial, were used to estimate hazard ratios (HRs) separately by CKD status at baseline, with further stratification by CKD stages (1, 2, 3a, 3b, and 4–5) and baseline categories of systolic blood pressure (in 10 mm Hg increments from <120 mm Hg to ≥170 mm Hg). Results A total of 268,615 participants from 45 randomised trials were included, of whom 55,716 met the criteria of a CKD diagnosis based on eGFR below 60 mL/min/1.73m2. Over a median follow-up of four years, each 5 mm Hg reduction in systolic blood pressure lowered the risk of major cardiovascular events in both individuals with CKD (HR 0.91, 95% confidence interval [CI] 0.87–0.94) and those without CKD at baseline (HR 0.90, 95% CI 0.88–0.92; P interaction > 0.99). We found no reliable evidence for heterogeneity of treatment effects by detailed CKD stages and systolic blood pressure categories at baseline (Figure). Conclusion Pharmacological blood pressure lowering should be considered for people at high risk of cardiovascular diseases regardless of CKD status, CKD stages and systolic blood pressure categories at the time of treatment initiation.Figure