Intensive Home Blood Pressure Lowering in Advanced CKD

When efforts at intensive blood pressure (BP) lowering are initiated for patients with advanced chronic kidney disease (CKD), there is a potential risk of acute kidney injury, hyperkalemia, and end-stage renal disease. Elaine Ku, MD, and colleagues conducted a nonblinded, randomized, controlled pilot trial to help determine whether lower home systolic BP (SBP) targets can be safely achieved in patients with CKD through titration of BP medications using in-home–measured BP. 

The study examined 108 patients with advanced CKD (estimated glomerular filtration rate ≤30 mL/min/1.73 m²) and hypertension who were randomized to either a target SBP goal of less than 120 mm Hg (n=66) or a less intensive goal (n=42). Antihypertensive medications were titrated to achieve the target home SBP range within the first four months of the study. The medications were maintained through the end of the study period. A wireless Bluetooth-enabled monitor was used to measure home BP and transmit real-time readings to clinicians.   

Efficacy and safety were evaluated. The primary efficacy outcome was the difference in achieved clinic SBP between the two study groups from months 4 through 12. The safety outcomes comprised hyperkalemia, a composite outcome of falls or syncope, and onset of a need for dialysis or kidney transplantation. 

The mean clinic SBP at month 12 was 124.7 mm Hg in the intensive SBP goal group and 138.2 mm Hg in the less intensive SBP goal group. The achieved mean clinic SBP in the intensive goal arm was 11.7 mm Hg (95% CI, 7.5-16; P<.001) lower than that achieved in the less intensive goal group on average over months 4 through 12. There was no statistically significant difference in safety outcomes between the two groups (all P>.05). 

The study found that a clinic SBP goal of less than 120 mm Hg can be safely achieved through real-time home BP monitoring in the study population. However, the sample size was small, so larger trials are needed to determine optimal BP targets for patients with advanced CKD and to assess the risks and benefits associated with more intensive BP control. 

Source: American Journal of Kidney Diseases