Almost All Adults With Hypertensive CKD Would Benefit From Lower Blood Pressure Target

Almost all participants in the SPRINT trial with hypertension and nondiabetic chronic kidney disease (CKD) stages 3–4 benefitted from a systolic blood pressure target of <120 mm Hg compared with a target of <140 mm Hg.1

These findings were presented at the American Society of Nephrology (ASN) Kidney Week 2025, held November 5-9, 2025, in Houston, Texas, by Alan Vera, a medical student at the University of California Davis.

“Optimal BP targets for adults with hypertension and CKD remain controversial. We used predicted risks and simulated preferences to estimate the individualized net benefit of intensive BP lowering among persons with CKD in the Systolic Blood Pressure Intervention Trial (SPRINT),” Vera and colleagues wrote.1

Vera and colleagues conducted a benefit-harm trade-off analysis of 2,012 participants with CKD, using Cox models to predict an absolute difference in risk between treatment targets for all-cause death, cardiovascular outcomes, cognitive outcomes, and BP treatment-related harms.

Participants had a mean age of 73 years (standard deviation, 9); 43% were female, 31% were Black, and baseline eGFR and albuminuria levels were 46 ±11 ml/min/1.73m2 and 16 (IQR, 7, 56) mg/g, respectively. The investigators found that when simulating preferences for participants who view the benefits of intensive BP lowering (reduction in death, cardiovascular events, and cognitive impairment) as much more important than treatment-related harms such as acute kidney injury and syncope, 100% had a positive net benefit in favor of intensive BP lowering, with a median net benefit of 6.4%.3

“This study demonstrates that evidence about blood pressure targets from SPRINT can be personalized to adults with hypertension and CKD by using each individual's estimated risks and preferences for multiple outcomes related to blood pressure lowering, which could help facilitate shared decision-making conversations,” Vera said in a statement.2

Furthermore, when benefits and harms were simulated to have similar importance in a sensitivity analysis, 90% had a positive net benefit, with a median net benefit of 2.2%. Importantly, people with more advanced CKD (eGFR 20–44 ml/min/1.73m2) had greater net benefits from a lower BP target than those with earlier-stage CKD (eGFR 45–59 ml/min/1.73m2) in both preference scenarios (P <.0001), with larger benefits outweighing experienced more treatment-related harms from a lower goal.1

The findings are consistent with KDIGO Guidelines that recommend a systolic BP target of <120 mm Hg for adults with hypertension and CKD. In its statement, ASN stressed that the data could help patients and care partners overcome therapeutic inertia that commonly occurs with intensifying blood pressure control in adults with CKD.2

On the other hand, other research presented during Kidney Week may challenge current guidelines on SGLT2 inhibitor use in patients with CKD regardless of diabetes status or baseline albuminuria. Natalie Staplin, PhD, Associate Professor of Medical Statistics at the University of Oxford, presented a new meta-analysis including 58,816 participants with (n = 48,946) and without (n = 9870) diabetes from 8 trials that found that allocation to an SGLT2 inhibitor slowed chronic eGFR decline by 57% (95%CI, 54-60) in people with diabetes and by 41% (95% CI, 33-49; P-het<0.001) in those without diabetes—a statistically significant benefit observed irrespective of albuminuria. SGLT2 inhibitor treatment also reduced kidney disease progression KDP by 32% (hazard ratio [HR], 0.68; 95% CI, 0.63-0.74), acute kidney injury by 21% (HR, 0.79; 95% CI, 0.70-0.90), all-cause mortality by 13% (HR, 0.87; 0.80-0.95), and hospitalizations by 11% (HR, 0.89; 95% CI, 0.85-0.93), with consistent effects across all subgroups.3

"If you've got a participant with low levels of albuminuria, our data supports starting them on an SGLT2 inhibitor just as much as people with higher levels of albuminuria, particularly looking at the participants without diabetes," Staplin told HCPLive during the meeting. "Our data support rethinking [the albumunuria threshold] and potentially removing it from the guidelines."

References

1. Vera AR, Scherzer R, Kravitz RL, et al. Individualized Net Benefit of Intensive Blood Pressure Lowering Among Persons with CKD in SPRINT. Presented at: ASN Kidney Week. Houston, Texas. November 05-09, 2025. # FR-OR040

2. Trial Analysis Reveals Almost All Adults with Hypertensive Chronic Kidney Disease Would Benefit from Intensive Blood Pressure Lowering. News release. ASN. November 7, 2025. https://www.newswise.com/articles/trial-analysis-reveals-almost-all-adults-with-hypertensive-chronic-kidney-disease-would-benefit-from-intensive-blood-pressure-lowering

3. Staplin N, Roddick AJ, Haynes R, Herrington WG. Net Effects of SGLT2 Inhibitors by Diabetes Status and Albuminuria. Presented at: ASN Kidney Week. Houston, Texas. November 05-09, 2025. #FR-OR086