Association between strict blood pressure control during chronic kidney disease and lower mortality after onset of end-stage renal disease

There is controversy regarding whether strict blood pressure control is indicated in chronic kidney disease (CKD) since the primary results of randomized controlled trials failed to show any impact on progression of kidney disease with this strategy. However, strict blood pressure control may have other beneficial effects beyond reducing the risk of end-stage renal disease (ESRD), such as lowering mortality after ESRD onset. The Modification of Diet in Renal Disease (MDRD) trial randomized 840 patients with CKD to strict (mean arterial pressure under 92 mm Hg) versus usual (mean arterial pressure under 107 mm Hg) blood pressure control between 1989 and 1993. Here we extended follow-up of study enrollees by linkage with United States Renal Data System and National Death Index to ascertain ESRD and vital status through 2010. Overall, 627 patients developed ESRD through 2010 with a median follow-up of 19.3 years. After ESRD onset, there were 142 deaths in the strict blood pressure arm and 182 deaths in the usual blood pressure arm (significant unadjusted hazard ratio for death was 0.72 (95% CI 0.58-0.89)). Overall, there were 212 deaths in the strict blood pressure control arm and 233 deaths in the usual arm (significant unadjusted hazard ratio for death 0.82 (95% CI 0.68-0.98)). Thus, although strict blood pressure control did not delay progression of CKD to ESRD, this strategy was associated with a lower risk of death after ESRD. Hence, long-term post-ESRD outcomes should be considered when formulating blood pressure targets for CKD.