Intensive BP Lowering Cuts CV Events Regardless of CKD Status

Intensive blood pressure (BP) lowering reduced the risk of major cardiovascular events by 15% for every 10-mm Hg reduction in systolic BP (SBP) among adults with and without chronic kidney disease (CKD), without increasing the risk of kidney failure, according to a systematic review and meta-analysis published in JAMA Cardiology.¹

The analysis was designed to address lingering uncertainty about whether patients with CKD gain the same cardiovascular benefit from tighter BP targets as the general population. A recent Cochrane meta-analysis restricted to CKD populations found no added cardiovascular benefit from intensive targets, and guideline recommendations have been inconsistent. The new review incorporates 3 large trials reported since then—ESPRIT, BPROAD, and STEP—which added 32,587 participants, including 1843 with CKD.

Cardiovascular Benefit Held Regardless of Kidney Function

Investigators searched MEDLINE and Embase through January 16, 2026, and identified 27 randomized clinical trials with 88,830 participants comparing intensive vs standard BP targets with at least 1 year of follow-up. Intensive targets varied across trials, most commonly a systolic BP below 120 mm Hg or below 130 mm Hg, while a few used diastolic or mean arterial pressure goals. Because the achieved BP gap between trial arms varied widely (1.3 to 15.4 mm Hg), they standardized each trial's result to a 10-mm Hg lower SBP. The overall achieved SBP reduction was nearly identical in CKD and non-CKD populations (11.1 vs 11.2 mm Hg).

Across 5640 cardiovascular events, intensive BP lowering reduced risk by 15% per 10-mm Hg lower SBP (relative risk [RR], 0.85; 95% CI, 0.81-0.89). The relative reduction was 11% among participants with CKD (RR, 0.89; 95% CI, 0.81-0.99) and 16% among those without CKD (RR, 0.84; 95% CI, 0.80-0.88), a difference the authors described as comparable (P = .26 for heterogeneity).

Because cardiovascular events were more common in people with CKD, the absolute benefit was at least as large in that group: an estimated 4.3 events avoided per 1000 person-years of treatment vs 2.7 among those without CKD. In an exploratory analysis, intensive BP lowering also reduced all-cause mortality by 11% per 10-mm Hg lower SBP (RR, 0.89; 95% CI, 0.83-0.95), with no evidence of heterogeneity by CKD status.

eGFR Declines Did Not Translate to More Kidney Failure

Intensive BP lowering did not affect kidney failure risk (RR, 0.97; 95% CI, 0.84-1.11), with similar results in CKD and non-CKD populations. Adding posttrial follow-up data, for a total of 1331 kidney failure outcomes, did not change that finding (RR, 0.93; 95% CI, 0.84-1.02).

However, intensive treatment raised the risk of sustained declines in estimated glomerular filtration rate (eGFR) of 30% or more by 42% (RR, 1.42; 95% CI, 1.28-1.58) and of 40% or more by 47% (RR, 1.47; 95% CI, 1.30-1.66). The increase for declines of 50% or more was not significant (RR, 1.29; 95% CI, 0.94-1.76).

The authors suggested the 30% and 40% declines may reflect hemodynamic effects of the additional diuretic therapy needed to reach lower targets. In ESPRIT, for example, 43% of the intensive arm used diuretics at study end vs 15% of the standard arm. They noted that "a small harm is not excluded" and advised careful monitoring of BP, eGFR, and electrolytes when implementing an intensive strategy. The authors also noted that intensive treatment has been associated with acute kidney injury and hypotension-related events, including syncope and falls, in prior research.

Guidelines Should Recommend Intensive Targets Amid Divergence

The 2025 American Heart Association/American College of Cardiology hypertension guideline sets a target SBP of less than 130 mm Hg and encourages less than 120 mm Hg, in line with the Kidney Disease: Improving Global Outcomes 2024 suggestion of less than 120 mm Hg for people with CKD.² The 2023 European Society of Hypertension guideline, by contrast, advises against actively aiming for SBP below 120 mm Hg.

The meta-analysis authors argued their data should encourage guidelines to recommend intensive BP lowering in patients with and without CKD.¹ They acknowledged limitations, including reliance on published trial-level rather than individual participant data, remaining uncertainty in patients with an eGFR below 30 mL/min/1.73 m², and differences in BP measurement methods across trials. The study was funded by a European Renal Association fellowship program, with no industry funding for the meta-analysis.

“While more intensive BP lowering increased the risk of sustained declines in kidney function, these did not translate into an increased risk of kidney failure, with a suggestion there are net benefits on mortality,” wrote the researchers of the study. “These data should encourage clinical guidelines to recommend intensive BP lowering in patients with and without CKD to reduce cardiovascular risk and encourage clinicians to implement such regimens with careful kidney function monitoring.”

References

1. 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
2. Kanbay M, Copur S, Sarafidis P, Ferro CJ, Ortiz A. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM guideline for the prevention, detection, evaluation and management of high blood pressure in adults: a commentary from the European Renal Best Practice (ERBP). Nephrol Dial Transplant. 2026;41(10):1909-1918. doi:10.1093/ndt/gfag055