Intensive vs Standard Blood Pressure Lowering in People With and Without Chronic Kidney Disease
A Systematic Review and Meta-Analysis.
This systematic review and meta-analysis of 27 RCTs (88,830 participants) demonstrates that intensive blood pressure lowering reduces major cardiovascular events by 15% per 10-mm Hg reduction in systolic pressure, regardless of chronic kidney disease status. While intensive lowering increased the risk of sustained eGFR declines, it did not raise the risk of kidney failure. Given the higher baseline cardiovascular risk in CKD, the absolute benefit (4.3 fewer events per 1,000 person-years) outweighs the renal surrogate changes, supporting intensive blood pressure targets in both CKD and non-CKD populations.
Objectives
To assess the standardized effects of intensive BP lowering on cardiovascular and kidney outcomes overall, and then to assess for effect modification by CKD status. DATA SOURCES: MEDLINE and Embase databases were searched from inception to January 16, 2026. STUDY SELECTION: Randomized clinical trials comparing intensive vs standard BP lowering in adults with and without CKD, with at least 1 year of follow-up, were eligible for inclusion. DATA EXTRACTION AND SYNTHESIS: Meta-analyses were performed using inverse variance weighting after standardizing trial results according to the between-group difference in achieved systolic BP (SBP). Differences in relative effects between CKD and non-CKD populations were assessed using χ2 tests for heterogeneity. MAIN OUTCOMES AND MEASURES: The primary outcome was major cardiovascular events; secondary outcomes included kidney failure and estimated glomerular filtration rate (eGFR)-based surrogate outcomes for kidney failure.
Results
We identified 27 studies including 88 830 participants. Intensive BP lowering reduced the risk of cardiovascular events by 15% per 10-mm Hg lower SBP (relative risk [RR], 0.85; 95% CI, 0.81-0.89), without heterogeneity by CKD status. This corresponded to an estimated (SE) absolute reduction of 4.3 (1.2) cardiovascular events per 1000 person-years in individuals with CKD and 2.7 (0.4) events per 1000 person-years in those without CKD. Intensive BP lowering did not affect risk of kidney failure (RR per 10-mm Hg reduction, 0.97; 95% CI, 0.84-1.11) nor risk of 57% or 50% sustained eGFR declines (RR, 0.97; 95% CI, 0.83-1.14; and RR, 1.29; 95% CI, 0.94-1.76, respectively), without heterogeneity by CKD subgroup. Intensive BP lowering increased risk of 30% or greater and 40% or greater declines by 42% (RR, 1.42; 95% CI, 1.28-1.58) and 47% (RR, 1.47; 95% CI, 1.30-1.66).
Conclusions
Results of this systematic review and meta-analysis indicate that in adults with or without CKD, intensive BP lowering reduced the risk of cardiovascular events by 15% per 10-mm Hg lower SBP and increased the risk of sustained declines in eGFR, without an increase in risk of kidney failure. However, since baseline cardiovascular risk is higher in CKD, the absolute reduction in cardiovascular events was at least as large in this population; therefore, intensive BP lowering should be recommended in people with and without CKD.
