Intensive blood pressure lowering reduced cardiovascular risk in people with and without CKD

Lowering systolic blood pressure to more intensive targets reduced the risk of major cardiovascular events by 15% for every 10 mm Hg drop, with similar effects in people with and without chronic kidney disease (CKD), according to a study published Oct. 7, 2026, in JAMA Cardiology.

Those with CKD face higher cardiovascular risk, and high blood pressure is tied to both heart and kidney disease. Since 2021, the nonprofit Kidney Disease: Improving Global Outcomes (KDIGO) has recommended a systolic target below 120 mm Hg for people with CKD. However, the authors of the study noted that the benefit of intensive lowering in established CKD has remained uncertain, leaving guideline targets inconsistent. A 2024 Cochrane meta-analysis limited to CKD populations found no added cardiovascular benefit from more intensive targets.

The study was led by co-authors Fotini Iatridi, Ph.D., assistant professor in nephrology at the Aristotle University of Thessaloniki (AUTH) School of Medicine in Greece, and Alistair J. Roddick, M.B.B.S., of the Renal Studies Group in the University of Oxford’s Nuffield Department of Population Health. Since the last major CKD-focused reviews, three large trials—ESPRIT, BPROAD and STEP—have reported results, adding 32,587 participants, including 1,843 with CKD. The team set out to test whether, with that newer evidence, effects differ by CKD status.

Researchers pooled 27 trials

Researchers searched the MEDLINE and Embase medical databases through January 2026 for randomized clinical trials comparing intensive vs. standard blood pressure targets in adults, with at least one year of follow-up. Trials in people on dialysis were excluded. The final analysis included 27 trials with 88,830 participants, 14 of which provided data on people with CKD. The most common intensive targets were a systolic pressure below 120 mm Hg or below 130 mm Hg.

Because the gap in achieved blood pressure between study groups ranged from 1.3 to 15.4 mm Hg across trials, the primary analysis adjusted each trial’s results to reflect the effect of a 10 mm Hg lower systolic pressure. Researchers also ran supporting analyses using unadjusted trial results and limiting the data to trials with more than 500 participants.

Heart benefits held regardless of kidney status

In the primary analysis, intensive lowering reduced the risk of major cardiovascular events by 15% per 10 mm Hg. The reduction was 11% in people with CKD and 16% in those without a difference that was not significant. Because people with CKD had more cardiovascular events to begin with, the estimated absolute benefit was at least as large in that group. Researchers estimated 4.2 events avoided per 1,000 person-years of treatment in people with CKD, compared with 2.7 in those without CKD.

Intensive lowering had no effect on kidney failure, generally defined as starting dialysis or receiving a kidney transplant. The result held when researchers added up to 10 years of posttrial follow-up data. It did, however, raise the risk of sustained declines in estimated glomerular filtration rate (eGFR), a measure of kidney function. The risk of a decline of 30% or more rose 42%, and the risk of a decline of 40% or more rose 47%. Declines of 50% or more were not significantly increased. In an exploratory analysis, all-cause mortality was 11% lower. Both supporting analyses produced similar results.

The authors noted that intensive groups in recent large trials relied more heavily on diuretics and calcium-channel blockers. At study end, 43% of the intensive group used diuretics vs. 15% of the standard group in ESPRIT, and 67% vs. 43% in the Systolic Blood Pressure Intervention Trial (SPRINT). The authors wrote that the eGFR drops may reflect the kidneys’ response to added diuretics, though a small kidney harm can’t be ruled out. They added that “it is prudent to monitor BP, eGFR, and electrolytes carefully when implementing an intensive strategy.”

Real-world practice has been slow to reach lower targets. A study published this year in the Journal of the American Society of Nephrology found that among roughly 50,000 patients with stage 3 or 4 CKD in the Mass General Brigham healthcare network each year, the share meeting the KDIGO target rose only from 18.3% in 2020 to 21.9% in 2024. In that analysis, patients above the target had higher risks of cardiovascular and kidney events.

More data needed in advanced CKD

The analysis included only randomized trials and standardized results so trials with very different blood pressure gaps could be compared, though 11 of the 27 trials raised some concerns about bias. The study relied mainly on published trial-level data rather than individual patient records, which limited subgroup analyses. Some participants counted as non-CKD may have had undiagnosed CKD, which could affect subgroup estimates but not the overall results, according to the authors.

Trials also measured blood pressure differently. Other research has linked intensive lowering to fainting and falls, the authors noted. The meta-analysis was funded by a European Renal Association fellowship with no industry funding, though several authors reported grants from Boehringer Ingelheim and Eli Lilly for other kidney trials.

The authors concluded that guidelines should recommend intensive blood pressure lowering for people with and without CKD to reduce cardiovascular risk, with clinicians monitoring kidney function carefully. They also called for more intensive vs. standard trials in people with an eGFR below 30 mL/min/1.73 m², where uncertainty about cardiovascular benefits remains.