Research in context
Evidence before this study
The 2017 American College of Cardiology and American Heart Association blood pressure guidelines based on systematic review and meta-analysis, recommended a systolic blood pressure goal of less than 130 mm Hg in people with and without diabetes. Findings of the Systolic Blood Pressure Intervention Trial (SPRINT) in individuals without diabetes showed a lower risk of cardiovascular disease events and all-cause mortality but a higher risk of incident chronic kidney disease with intensive lowering of systolic blood pressure (goal <120 mm Hg) compared with standard systolic blood pressure control (goal <140 mm Hg). Whether the magnitude of increased incidence of chronic kidney disease with intensive lowering of systolic blood pressure is higher in people with type 2 diabetes compared with those without diabetes is not known.
Added value of this study
In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial in people with type 2 diabetes, a systolic blood pressure intervention was tested similar to that assessed in SPRINT. Despite a clinically similar reduction in systolic blood pressure in both the ACCORD trial and SPRINT, at 3 years, the absolute risk difference between the intensive and standard interventions for incident chronic kidney disease was 5·9% (95% CI 4·3–7·5) in the ACCORD trial and 2·5% (1·8–3·2) in SPRINT (p=0·0001 for interaction).
Implications of all the available evidence
The risk of incident chronic kidney disease was higher in people with type 2 diabetes than in those without this disease with intensive systolic blood pressure lowering. Chronic kidney disease is known to be a risk factor for future cardiovascular events. However, it is unclear whether incident chronic kidney disease due to intensive lowering of systolic blood pressure increases the risk of future cardiovascular events. Further studies are warranted to ascertain whether the higher risk of incident chronic kidney disease with intensive lowering of systolic blood pressure is outweighed by the expected reductions in cardiovascular disease and all-cause mortality in type 2 diabetes in the long term.