Author + information
- Miguel Bigotte Vieira, MD∗ (, )
- Rita Magriço, MD,
- Catarina Viegas Dias, MD,
- Lia Leitão, MD and
- João Sérgio Neves, MD
- ↵∗Nephrology and Renal Transplantation Department, Centro Hospitalar Lisboa Norte, Avenida Professor Egas Moniz, 1649-035 Lisbon, Portugal
We read with interest the paper by Philips et al. (1) reporting the effect of baseline 10-year cardiovascular disease risk on primary outcome events and all-cause serious adverse events in SPRINT (Systolic Blood Pressure Intervention Trial). The authors concluded that patients with lower baseline cardiovascular risk had more harm than benefit from intensive treatment, whereas those with higher risk had more benefit. We agree that these results may help physicians make decisions regarding blood pressure treatment in high-risk patients (2).
Although the authors have included in their analysis the serious adverse events, including acute kidney injury/acute renal failure, they have not evaluated the occurrence of long-term renal outcomes. In SPRINT (3), in patients without prior kidney disease, intensive treatment was associated with a higher incidence of kidney function decline, defined by a >30% reduction in estimated glomerular filtration rate to <60 ml/min/1.73 m2 on 2 determinations with 3-month intervals (hazard ratio: 3.49; 95% confidence interval: 2.44 to 5.10; p < 0.001). This highlights the importance of considering long-term renal outcomes in the risk-benefit evaluation of intensive treatment.
Using the SPRINT Data Analysis Challenge dataset (4), we evaluated the risk-benefit of intensive treatment focusing on the balance between cardiovascular events or death and kidney function decline (5). We found that, in patients without chronic kidney disease, larger declines in mean arterial pressure (MAP) were associated with a higher incidence of kidney function decline. In a propensity score analysis, MAP reduction <20 mm Hg presented a number needed to treat (NNT) (cardiovascular events or death) of 44 and a number needed to harm (NNH) (kidney function decline) of 65; MAP reduction between 20 and <40 mm Hg presented an NNT of 42 and an NNH of 35; and MAP reduction >40 mm Hg presented an NNT of 95 and an NNH of 16. Thus, intensive treatment seemed to be less favorable when a larger reduction in MAP was needed to attain the blood pressure target.
In the paper by Philips et al. (1), the authors detected more hypotension in the intensive group in the fourth quartile and more acute kidney injury/acute renal failure in the intensive group in the second, third, and fourth quartiles. This highlights that these groups may also have presented different outcomes regarding long-term renal outcomes.
In summary, we believe it would have also been important to take into consideration the occurrence of long-term renal outcomes in SPRINT to fully evaluate the risk-benefit of intensive treatment.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- Phillips R.A.,
- Xu J.,
- Peterson L.E.,
- Arnold R.M.,
- Diamond J.A.,
- Schussheim A.E.
- White W.B.
- Magriço R.,
- Bigotte Vieira M.,
- Viegas Dias C.,
- Leitão L.,
- Neves J.S.