Guiding Lights for Antihypertensive Treatment in Patients with Nondiabetic Chronic Renal Disease: Proteinuria and Blood Pressure Levels?

In the United States, about 20 million adults have chronic kidney disease (1). Many also have hypertension, either as a cause or complication of the kidney disease. Recently released guidelines from the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) recommended aggressive treatment of hypertension to target blood pressure values less than 130/80 mm Hg in patients with chronic kidney disease (2). The guidelines defined chronic kidney disease as either reduced excretory function (estimated glomerular filtration rate < 60 mL/min per 1.73 m², corresponding approximately to a creatinine level > 132.6 µmol/L [>1.5 mg/dL] in men or >114.9 µmol/L [>1.3 mg/dL] in women) or the presence of urinary findings, such as albuminuria (>300 mg/d or 200 mg of albumin per g of creatinine). Stated goals of aggressive blood pressure management were to slow deterioration of renal function and prevent cardiovascular disease. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers were listed as first-line agents of choice for patients with either diabetic or nondiabetic renal disease. The guidelines did not address whether the target blood pressure should vary depending on severity of renal disease.

In this issue, an important and carefully conducted meta-analysis from Jafar and colleagues brings to the forefront three points relevant to the management of patients with nondiabetic kidney disease and hypertension (3). Does urinary protein excretion level affect outcomes? Are blood pressure targets less than 130/80 mm Hg too high? Should clinicians use both urinary protein and blood pressure levels during follow-up to guide management?

In the individual-patient meta-analysis, Jafar and colleagues summarized renal function outcomes from 11 randomized trials that had compared effects of antihypertensive regimens with or without ACE inhibitors. Patients in the trials had high blood pressure, decreased kidney function, or both. They …