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Relationship between the lower limit of systolic blood pressure target and kidney function decline in advanced chronic kidney disease: an instrumental variable analysis from the REACH-J CKD cohort study

Hypertension Research volume 46, pages 2478–2487 (2023)Cite this article

A Comment to this article was published on 02 October 2023

Abstract

Intensive antihypertensive treatment decreases cardiovascular disease and mortality risks in chronic kidney disease (CKD), whereas extremely low systolic blood pressure (SBP) is associated with worsening kidney function and poor prognosis. Although the SBP variation is particularly large in patients with CKD, the optimal lower limit of SBP target is unclear. In a nationwide, multicenter cohort study of patients with an estimated glomerular filtration rate (eGFR) < 45 mL/min/1.73 m2, we evaluated the association between the eGFR slopes and the lower limit of SBP target at ≥110 mmHg using a linear mixed-effects model and an instrumental variable method. The instrumental variable was calculated as the facility-level percentage of nephrologists who answered in the survey that their lower limit of SBP target was 110 mmHg or higher. A total of 1320 patients (mean age 70 years; 66% men) were included. The mean eGFR slope ± standard deviation over the four years to baseline was –2.48 ± 2.15 mL/min/1.73 m2/year. The instrumental variable for the lower limit of SBP target at ≥110 mmHg (vs. ≤100 mmHg) was associated with less eGFR decline (coefficient: +1.05 mL/min/1.73 m2/year; 95% confidence interval: 0.33–1.77), while unassociated with a history of cardiovascular disease. The renoprotective effect was particularly larger in the subgroups of the elderly and those with a history of cardiovascular disease. In conclusion, the lower limit of SBP target at 110 mmHg or higher was associated with improved eGFR slope, suggesting the importance of aiming at avoiding excessively low SBP in patients with advanced CKD.

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Acknowledgements

We thank all the nephrology specialists in Japan who responded to our Reach-J survey, the Scientific Committee: Dr. Kunitoshi Iseki, Dr. Kouichi Asahi, Dr. Junichi Hoshino, the staff members of Department of Nephrology, University of Tsukuba: Dr. Chie Saito, Dr. Hirayasu Kai, Dr. Kei Nagai, Dr. Ryoya Tsunoda, the staff members of Department of Health Care Policy and Health Economics, University of Tsukuba: Dr. Masahide Kondo, Dr. Reiko Okubo, Ms. Yukiko Ito, all the staff members of the Tsukuba Clinical Research & Development Organization (T-CReDO), University of Tsukuba, and Mr. Yoshihiro Ishihara and other staff members of Flexible Inc., for their contribution to our work.

the REACH-J CKD collaborators

Tomoya Hirayama8, Nobuhiko Togashi9, Akira Sugiura10, Kunihiro Yamagata11, Tatsuo Shiigai12, Kazue Ueki13, Ken Kikkawa14, Tsukasa Nakamura15, Eiichi Sato15, Hideki Matsukuma16, Shinsuke Harasawa17, Takehiko Washio17, Yuko Shibuya18, Hitoshi Tagawa19, Takashi Yasuda19, Shuzo Kobayashi20, Masaki Nagasawa21, Minako Wakasugi22, Hajime Yamazaki23, Michio Matsumoto24, Shoichi Maruyama25, Norihiro Suga26, Keiichi Tamagaki27, Taiko Kimura28, Tsutomu Tabata29, Yoshihiro Tsujimoto29, Shinichi Nishi30, Yuriko Yonekura31, Hitoshi Sugiyama32, Naoki Kashihara33, Tadashi Sofue34, Kazuhiko Tsuruya35, Toshiaki Nakano35, Masato Tadokoro36, Shoichi Fujimoto37, Masao Kikuchi37, Kiyoyuki Tokuyama38

Funding

This study was supported by a Grant-in-Aid for Research on Advanced Chronic Kidney Disease (REACH-J), Practical Research Project for Renal Diseases from the Japan Agency for Medical Research and Development (AMED under grant numbers: JP17ek0310005 and JP20ek0310010).

Author information

Authors and Affiliations

  1. Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan

    Shimon Kurasawa, Yoshinari Yasuda, Sawako Kato & Shoichi Maruyama

  2. Department of Clinical Research Education, Nagoya University Graduate School of Medicine, Nagoya, Japan

    Shimon Kurasawa

  3. Department of Nephrology, Saitama Medical University, Saitama, Japan

    Hirokazu Okada

  4. Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan

    Naoki Kashihara

  5. Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan

    Ichiei Narita

  6. Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan

    Takashi Wada

  7. Department of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan

    Kunihiro Yamagata

  8. Kitasaito Hospital, Hokkaido, Japan

    Tomoya Hirayama

  9. JR Sapporo Hospital, Hokkaido, Japan

    Nobuhiko Togashi

  10. Osaki Citizen Hospital, Miyagi, Japan

    Akira Sugiura

  11. University of Tsukuba, Ibaraki, Japan

    Kunihiro Yamagata

  12. Shiigai Clinic, Ibaraki, Japan

    Tatsuo Shiigai

  13. Toho Hospital, Gunma, Japan

    Kazue Ueki

  14. Kikkawa Naika Clinic, Saitama, Japan

    Ken Kikkawa

  15. Shinmatsudo Central General Hospital, Chiba, Japan

    Tsukasa Nakamura & Eiichi Sato

  16. Funabashi Futawa Hospital, Chiba, Japan

    Hideki Matsukuma

  17. Nihon University Hospital, Tokyo, Japan

    Shinsuke Harasawa & Takehiko Washio

  18. NTT Medical Center Tokyo, Tokyo, Japan

    Yuko Shibuya

  19. Kichijoji Asahi Hospital, Tokyo, Japan

    Hitoshi Tagawa & Takashi Yasuda

  20. Shonan-Kamakura General Hospital, Kanagawa, Japan

    Shuzo Kobayashi

  21. Shinonoi General Hospital, Nagano, Japan

    Masaki Nagasawa

  22. Niigata University Hospital, Niigata, Japan

    Minako Wakasugi

  23. Nagaoka Red Cross Hospital, Niigata, Japan

    Hajime Yamazaki

  24. Toyama Saiseikai Toyama Hospital, Toyama, Japan

    Michio Matsumoto

  25. Nagoya University Hospital, Aichi, Japan

    Shoichi Maruyama

  26. Nagoya City West Medical Center, Aichi, Japan

    Norihiro Suga

  27. Kyoto Prefectural University of Medicine Hospital, Kyoto, Japan

    Keiichi Tamagaki

  28. Nantan Hospital, Kyoto, Japan

    Taiko Kimura

  29. Inoue Hospital, Osaka, Japan

    Tsutomu Tabata & Yoshihiro Tsujimoto

  30. Kobe University Hospital, Hyogo, Japan

    Shinichi Nishi

  31. Akashi Medical Center, Hyogo, Japan

    Yuriko Yonekura

  32. Okayama University Hospital, Okayama, Japan

    Hitoshi Sugiyama

  33. Kawasaki Medical School Hospital, Okayama, Japan

    Naoki Kashihara

  34. Kagawa University Hospital, Kagawa, Japan

    Tadashi Sofue

  35. Kyushu University Hospital, Fukuoka, Japan

    Kazuhiko Tsuruya & Toshiaki Nakano

  36. Nagasaki Harbor Medical Center City Hospital, Nagasaki, Japan

    Masato Tadokoro

  37. University of Miyazaki Hospital, Miyazaki, Japan

    Shoichi Fujimoto & Masao Kikuchi

  38. Tokuyama Clinic, Okinawa, Japan

    Kiyoyuki Tokuyama

Authors
  1. Shimon Kurasawa
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  2. Yoshinari Yasuda
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  3. Sawako Kato
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  4. Shoichi Maruyama
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  5. Hirokazu Okada
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  6. Naoki Kashihara
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  7. Ichiei Narita
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  8. Takashi Wada
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  9. Kunihiro Yamagata
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Consortia

the REACH-J CKD collaborators

  • Tomoya Hirayama
  • , Nobuhiko Togashi
  • , Akira Sugiura
  • , Kunihiro Yamagata
  • , Tatsuo Shiigai
  • , Kazue Ueki
  • , Ken Kikkawa
  • , Tsukasa Nakamura
  • , Eiichi Sato
  • , Hideki Matsukuma
  • , Shinsuke Harasawa
  • , Takehiko Washio
  • , Yuko Shibuya
  • , Hitoshi Tagawa
  • , Takashi Yasuda
  • , Shuzo Kobayashi
  • , Masaki Nagasawa
  • , Minako Wakasugi
  • , Hajime Yamazaki
  • , Michio Matsumoto
  • , Shoichi Maruyama
  • , Norihiro Suga
  • , Keiichi Tamagaki
  • , Taiko Kimura
  • , Tsutomu Tabata
  • , Yoshihiro Tsujimoto
  • , Shinichi Nishi
  • , Yuriko Yonekura
  • , Hitoshi Sugiyama
  • , Naoki Kashihara
  • , Tadashi Sofue
  • , Kazuhiko Tsuruya
  • , Toshiaki Nakano
  • , Masato Tadokoro
  • , Shoichi Fujimoto
  • , Masao Kikuchi
  •  & Kiyoyuki Tokuyama

Corresponding author

Correspondence to Shimon Kurasawa.

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Conflict of interest

YY has received honoraria from Astellas, AstraZeneca, Kowa, Mitsubishi Tanabe, and Mochida. SM has received grants and/or research funding from Chugai, Mitsubishi Tanabe, Ono, and ROHTO; honoraria from Alexion, Astellas, AstraZeneca, Bayer, and Mitsubishi Tanabe. HO has received honoraria from Astellas, AstraZeneca, Daiichi Sankyo, Kyowa Kirin, Mitsubishi Tanabe, and Torii. NK has received consulting fees from Kyowa Kirin and Novo Nordisk; honoraria from Astellas, AstraZeneca, Kyowa Kirin, Novartis, Ono, and Otsuka; payment for expert testimony from Kissei and Kyowa Kirin. KY has received grants from Kyowa Kirin and Mitsubishi Tanabe. All other authors reported no conflicts of interest.

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Kurasawa, S., Yasuda, Y., Kato, S. et al. Relationship between the lower limit of systolic blood pressure target and kidney function decline in advanced chronic kidney disease: an instrumental variable analysis from the REACH-J CKD cohort study. Hypertens Res 46, 2478–2487 (2023). https://doi.org/10.1038/s41440-023-01358-z

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