The Effect of a Lower Target Blood Pressure on the Progression of Kidney Disease: Long-Term Follow-up of the Modification of Diet in Renal Disease Study

  1. Mark J. Sarnak, MD;
  2. Tom Greene, PhD;
  3. Xuelei Wang, MS;
  4. Gerald Beck, PhD;
  5. John W. Kusek, PhD;
  6. Allan J. Collins, MD; and
  7. Andrew S. Levey, MD
  1. From Tufts-New England Medical Center, Boston, Massachusetts; Cleveland Clinic Foundation, Cleveland, Ohio; National Institute of Health, Bethesda, Maryland; and U.S. Renal Data System, Minneapolis, Minnesota.

    Abstract

    Background: Hypertension is a risk factor for progression of chronic kidney disease. The optimal blood pressure to slow progression is unknown.

    Objective: To evaluate the effects of a low target blood pressure on kidney failure and all-cause mortality.

    Design: Long-term follow-up of the Modification of Diet in Renal Disease Study, a randomized, controlled trial conducted from 1989 to 1993.

    Setting: 15 outpatient nephrology practices.

    Participants: 840 persons with predominantly nondiabetic kidney disease and a glomerular filtration rate of 13 to 55 mL/min per 1.73 m2.

    Intervention: A low target blood pressure (mean arterial pressure < 92 mm Hg) or a usual target blood pressure (mean arterial pressure < 107 mm Hg).

    Measurements: After the randomized trial was completed, kidney failure (defined as initiation of dialysis or kidney transplantation) and a composite outcome of kidney failure or all-cause mortality were ascertained through 31 December 2000.

    Results: Kidney failure occurred in 554 participants (66%), and the composite outcome occurred in 624 participants (74%). After Cox proportional hazards modeling and intention-to-treat analysis, the adjusted hazard ratios were 0.68 (95% CI, 0.57 to 0.82; P < 0.001) for kidney failure and 0.77 (CI, 0.65 to 0.91; P = 0.0024) for the composite outcome in the low target blood pressure group compared with the usual target blood pressure group. Evidence was insufficient to conclude that the benefit of a low target blood pressure differed according to the cause of kidney disease, baseline glomerular filtration rate, or degree of proteinuria.

    Limitations: The exact mechanism underlying the benefit of a low target blood pressure is unknown.

    Conclusions: Assignment to a low target blood pressure slowed the progression of nondiabetic kidney disease in patients with a moderately to severely decreased glomerular filtration rate.

    Article and Author Information

    • Presented in part at the 2003 Annual Meeting of the American Society of Nephrology, San Diego, California, 14 to 17 November 2003.

    • Grant Support: By grants K23 DK 02904 and UO1 DK 35073 from the National Institutes of Diabetes and Digestive and Kidney Diseases.

    • Potential Financial Conflicts of Interest: None disclosed.

    • Requests for Single Reprints: Mark J. Sarnak, MD, Box 391, Division of Nephrology, Tufts-New England Medical Center, 750 Washington Street, Boston, MA 02111; e-mail, msarnak{at}tufts-nemc.org.

    • Current Author Addresses: Drs. Sarnak and Levey: Division of Nephrology, Tufts-New England Medical Center, 750 Washington Street, Boston, MA 02111.

    • Drs. Greene, Wang, and Beck: Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.

    • Dr. Kusek: National Institutes of Health, Room 617, 6707 Democracy Boulevard, Bethesda, MD 20817.

    • Dr. Collins: U.S. Renal Data System, 914 South 8th Street, D-206, Minneapolis, MN 55404.

    • Author Contributions: Conception and design: M.J. Sarnak, T. Greene, G. Beck, J.W. Kusek, A.J. Collins, A.S. Levey.

    • Analysis and interpretation of the data: M.J. Sarnak, T. Greene, X. Wang, G. Beck, J.W. Kusek, A.S. Levey.

    • Drafting of the article: M.J. Sarnak, T. Greene, A.S. Levey.

    • Critical revision of the article for important intellectual content: M.J. Sarnak, T. Greene, G. Beck, J.W. Kusek, A.S. Levey.

    • Final approval of the article: M.J. Sarnak, T. Greene, X. Wang, G. Beck, J.W. Kusek, A.J. Collins, A.S. Levey.

    • Provision of study materials or patients: A.J. Collins, A.S. Levey.

    • Statistical expertise: T. Greene, X. Wang, G. Beck.

    • Obtaining of funding: M.J. Sarnak, G. Beck, J.W. Kusek, A.S. Levey.

    • Administrative, technical, or logistic support: M.J. Sarnak, G. Beck, A.S. Levey.

    • Collection and assembly of data: M.J. Sarnak, T. Greene, G. Beck, J.W. Kusek, A.J. Collins.

    Responses to this article

      • Mark J. Sarnak and
      • Tom Greene, PhD and Andrew S. Levey, MD
      Ann Intern Med published online October 26, 2009
    • MDRD Revisited: What about death?
      • Chester B Good
      Ann Intern Med published online October 26, 2009
    • blood pressure and kidney disease
      • Yujiro Kida
      Ann Intern Med published online October 26, 2009

    Summary for Patients

    • Summaries for Patients:A Low Blood Pressure Target Prevented Kidney Failure in Patients with Chronic Kidney Disease Ann Intern Med March 1, 2005 142:I-42
    « Previous | Next Article »Table of Contents

    This Article

    1. Ann Intern Med March 1, 2005 vol. 142 no. 5 342-351
    1. » Abstract
    2. Figures
    3. Full Text
    4. Full Text (PDF)
      1. Summary for Patients

    Current Issue

    1. November 17, 2009, 151 (10)
    1. Alert me to current issues