BP-Lowering Reduces Cardiovascular Risk Across All CKD Stages, with Attenuated Benefit in Diabetes

Blood pressure (BP)-lowering treatment significantly reduces the risk of major cardiovascular events in individuals with chronic kidney disease (CKD) across all stages, with effects comparable to those without CKD, although benefits are diminished in patients with coexisting diabetes. This one-stage individual-participant meta-analysis included 52 randomized controlled trials, of which 46 trials (285,124 participants) met strict eligibility criteria, including adequate follow-up, baseline BP and creatinine data, and adjudicated time-to-event outcomes. Among participants, 20.7% had CKD at baseline and 30.2% had type 2 diabetes, with a balanced representation of sexes and no age restriction. Over a median follow-up of 4.4 years, each 5 mm Hg reduction in systolic BP was associated with a 9–10% proportional reduction in major cardiovascular events—defined as a composite of stroke, ischemic heart disease, or heart failure outcomes—in both CKD and non-CKD populations, with no evidence of heterogeneity. Importantly, this benefit was consistent across all CKD stages (1–5), including advanced stages 4–5, and was not modified by baseline BP levels, extending even to individuals with readings below 120/70 mm Hg. Similarly, treatment effects were uniform regardless of the presence or absence of proteinuria, suggesting that albuminuria status does not materially influence relative cardiovascular benefit. However, a key nuance emerged in subgroup analyses: among individuals with CKD, those with concomitant diabetes experienced a smaller relative risk reduction (HR 0.96) compared to those without diabetes (HR 0.88), indicating a statistically significant interaction and suggesting differing therapeutic responsiveness. Furthermore, stratified network meta-analysis across five major antihypertensive drug classes demonstrated that class-specific efficacy in reducing cardiovascular risk was consistent across CKD subgroups, indicating no preferential drug class based solely on CKD stage or proteinuria. These findings reinforce that BP lowering is broadly effective and should be a cornerstone of cardiovascular risk reduction in CKD, while also highlighting the need for more tailored or intensified strategies in patients with both CKD and diabetes, who remain at particularly high residual risk. Source: https://www.thelancet.com/