Intensive BP Lowering Reduces Cardiovascular Events Regardless of CKD Status

Intensive blood pressure (BP) lowering reduced the risk of major cardiovascular events by 15% for each 10-mm Hg lower systolic BP (SBP) in adults with or without chronic kidney disease (CKD), according to a systematic review and meta-analysis published in JAMA Cardiology.

The investigators wrote that the effects of intensive BP lowering in established CKD remain uncertain, which has led to inconsistent BP-target recommendations across guidelines. Their updated analysis added 3 large trials reported since earlier CKD-focused meta-analyses: ESPRIT, BPROAD, and STEP. To compare trials, the investigators standardized treatment effects per 10-mm Hg difference in achieved SBP and then tested whether effects differed by CKD status.

The analysis included 27 randomized clinical trials with 88,830 participants and an average within-trial follow-up of 1 to 8.4 years. Intensive BP lowering reduced the risk of major cardiovascular events (the primary outcome; relative risk [RR], 0.85; 95% CI, 0.81-0.89), with no heterogeneity by CKD status. The estimated absolute reduction was 4.3 events per 1000 person-years in participants with CKD and 2.7 events per 1000 person-years in those without CKD.

Intensive BP lowering did not affect the risk of kidney failure (RR per 10-mm Hg reduction, 0.97; 95% CI, 0.84-1.11). However, it increased the risk of sustained declines in estimated glomerular filtration rate (eGFR) of 30% or greater by 42% and of 40% or greater by 47%. The authors said these declines may reflect hemodynamic responses to the additional diuretic therapy needed to reach lower targets, but they noted that a small harm cannot be excluded.

The investigators also listed limitations. They relied mainly on trial-level tabular data rather than individual participant data. Some participants in the non-CKD analyses may have had unrecognized CKD. Trials also measured BP in different ways. The authors added that more trials are needed in patients with an eGFR below 30 mL/min/1.73 m². They concluded that guidelines should recommend intensive BP lowering in people with and without CKD, with careful monitoring of kidney function.

Source: Iatridi F, Roddick AJ, Staplin N, et al. Intensive vs standard blood pressure lowering in people with and without chronic kidney disease: a systematic review and meta-analysis. JAMA Cardiol. Published online October 7, 2026. doi:10.1001/jamacardio.2026.4445