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Progression of Chronic Kidney Disease: The Role of Blood Pressure Control, Proteinuria, and Angiotensin-Converting Enzyme Inhibition: A Patient-Level Meta-Analysis

Tazeen H. JafarFrom TuftsNew England Medical Center, Boston, Massachusetts; The Aga Khan University, Karachi, Pakistan; Ospedale Civile Maggiore, Verona, Italy; University of Groningen, Groningen, the Netherlands; Merck Research Laboratories, West Point, Pennsylvania; and University of Texas at Southwestern Medical Center, Dallas, TexasPaul C. StarkThe Aga Khan University, Karachi, PakistanChristopher H. SchmidFrom TuftsNew England Medical Center, Boston, Massachusetts; The Aga Khan University, Karachi, Pakistan; Ospedale Civile Maggiore, Verona, Italy; University of Groningen, Groningen, the Netherlands; Merck Research Laboratories, West Point, Pennsylvania; and University of Texas at Southwestern Medical Center, Dallas, TexasMarcia LandaThe Aga Khan University, Karachi, PakistanGiuseppe MaschioUniversity of Texas at Southwestern Medical Center, Dallas, TexasPaul E. de JongOspedale Civile Maggiore, Verona, ItalyDick de ZeeuwUniversity of Texas at Southwestern Medical Center, Dallas, TexasShahnaz ShahinfarUniversity of Groningen, Groningen, the NetherlandsRobert D. TotoFrom TuftsNew England Medical Center, Boston, Massachusetts; The Aga Khan University, Karachi, Pakistan; Ospedale Civile Maggiore, Verona, Italy; University of Groningen, Groningen, the Netherlands; Merck Research Laboratories, West Point, Pennsylvania; and University of Texas at Southwestern Medical Center, Dallas, TexasAndrew S. LeveyMerck Research Laboratories, West Point, Pennsylvaniafor the AIPRD Study Group*

2003en

ABI

Annotatsiya

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors reduce blood pressure and urine protein excretion and slow the progression of chronic kidney disease. PURPOSE: To determine the levels of blood pressure and urine protein excretion associated with the lowest risk for progression of chronic kidney disease during antihypertensive therapy with and without ACE inhibitors. DATA SOURCES: 11 randomized, controlled trials comparing the efficacy of antihypertensive regimens with or without ACE inhibitors for patients with predominantly nondiabetic kidney disease. STUDY SELECTION: MEDLINE database search for English-language studies published between 1977 and 1999. DATA EXTRACTION: Data on 1860 nondiabetic patients were pooled in a patient-level meta-analysis. Progression of kidney disease was defined as a doubling of baseline serum creatinine level or onset of kidney failure. Multivariable regression analysis was performed to assess the association of systolic and diastolic blood pressure and urine protein excretion with kidney disease progression at 22 610 patient visits. DATA SYNTHESIS: Mean duration of follow-up was 2.2 years. Kidney disease progression was documented in 311 patients. Systolic blood pressure of 110 to 129 mm Hg and urine protein excretion less than 2.0 g/d were associated with the lowest risk for kidney disease progression. Angiotensin-converting enzyme inhibitors remained beneficial after adjustment for blood pressure and urine protein excretion (relative risk, 0.67 [95% CI, 0.53 to 0.84]). The increased risk for kidney progression at higher systolic blood pressure levels was greater in patients with urine protein excretion greater than 1.0 g/d (P < 0.006). CONCLUSION: Although reverse causation cannot be excluded with certainty, a systolic blood pressure goal between 110 and 129 mm Hg may be beneficial in patients with urine protein excretion greater than 1.0 g/d. Systolic blood pressure less than 110 mm Hg may be associated with a higher risk for kidney disease progression.

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DOI: 10.7326/0003-4819-139-4-200308190-00006

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