Intensive Home Blood Pressure Lowering in Patients with Advanced CKD

Elaine Ku; Timothy P Copeland; Charles E McCulloch; Divya Seth; Christopher A Carlos; Kerry Cho; Anna Malkina; Lowell J Lo; Raymond K Hsu

doi:10.1053/j.ajkd.2024.08.010

Intensive Home Blood Pressure Lowering in Patients with Advanced CKD

Am J Kidney Dis. 2024 Oct 18:S0272-6386(24)01036-9. doi: 10.1053/j.ajkd.2024.08.010. Online ahead of print.

Authors

Elaine Ku¹, Timothy P Copeland², Charles E McCulloch³, Divya Seth², Christopher A Carlos², Kerry Cho², Anna Malkina², Lowell J Lo², Raymond K Hsu²

Affiliations

¹ Division of Nephrology, Department of Medicine, University of California, San Francisco. Electronic address: [email protected].
² Division of Nephrology, Department of Medicine, University of California, San Francisco.
³ Department of Epidemiology and Biostatistics, University of California, San Francisco.

PMID: 39427725
DOI: 10.1053/j.ajkd.2024.08.010

Abstract

Rationale & objective: Optimal blood pressure (BP) targets in advanced CKD are controversial. More intensive BP lowering in the setting of advanced CKD is thought to be associated with risk of acute kidney injury, hyperkalemia, and ESKD. We aimed to conduct a pilot trial of intensive BP control to determine if lower SBP targets can be safely achieved for patients with CKD through titration of BP medications using in-home measured BP.

Study design: Non-blinded randomized controlled trial.

Settings & participants: 108 patients with advanced CKD (eGFR ≤30 mL/min/1.73 m²) and hypertension.

Interventions: Participants were randomized either to a target home SBP goal of <120 mmHg (N=66) or a less intensive SBP goal (N=42). Antihypertensive medications were titrated to achieve the target home SBP range in the first 4 months of the study and maintained until the end of the study. Home BP was measured using a wireless Bluetooth-enabled monitor that transmitted readings to providers in real-time.

Outcomes: The primary efficacy outcome was the difference in achieved clinic SBP between the two study arms from months 4-12. Safety outcomes included hyperkalemia, a composite outcome of falls or syncope, and onset of need for dialysis or kidney transplantation.

Results: The mean clinic SBP at month 12 was 124.7 mmHg in the intensive SBP group vs. 138.2 mmHg in the less intensive SBP group. Averaged over months 4-12, the achieved mean clinic SBP in the intensive SBP arm was 11.7 mmHg (95% CI 7.5 to 16 mmHg, p<0.001) lower than the mean SBP achieved in the less intensive SBP arm. Primary safety outcomes were not statistically significantly different between the two arms (all p>0.05).

Limitations: Small sample size which may limit our ability to detect clinically significant differences in rates of adverse outcomes; single-center design.

Conclusions: A clinic SBP goal of <120 mmHg is feasible to achieve with the help of real-time home BP monitoring and appears to be safe in this study population with advanced CKD. Larger trials to determine optimal BP targets in advanced CKD and the risks and benefits associated with more intensive BP control are warranted.