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Arch Intern Med. 2008;168(8):832-839.

Background  Antihypertensive drugs that block the renin-angiotensin system (angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers) are recommended for patients with chronic kidney disease (CKD). A low blood pressure (BP) goal (BP, <130/80 mm Hg) is also recommended. The objective of this study was to determine the long-term effects of currently recommended BP therapy in 1094 African Americans with hypertensive CKD.

Methods  Multicenter cohort study following a randomized trial. Participants were 1094 African Americans with hypertensive renal disease (glomerular filtration rate, 20-65 mL/min/1.73 m²). Following a 3x2-factorial trial (1995-2001) that tested 3 drugs used as initial antihypertensive therapy (ACEIs, calcium channel blockers, and β-blockers) and 2 levels of BP control (usual and low), we conducted a cohort study (2002-2007) in which participants were treated with ACEIs to a BP lower than 130/80 mm Hg. The outcome measures were a composite of doubling of the serum creatinine level, end-stage renal disease, or death.

Results  During each year of the cohort study, the annual use of an ACEI or an angiotensin receptor blocker ranged from 83.7% to 89.0% (vs 38.5% to 49.8% during the trial). The mean BP in the cohort study was 133/78 mm Hg (vs 136/82 mm Hg in the trial). Overall, 567 participants experienced the primary outcome; the 10-year cumulative incidence rate was 53.9%. Of 576 participants with at least 7 years of follow-up, 33.5% experienced a slow decline in kidney function (mean annual decline in the estimated glomerular filtration rate, <1 mL/min/1.73 m²).

Conclusion  Despite the benefits of renin-angiotensin system–blocking therapy on CKD progression, most African Americans with hypertensive CKD who are treated with currently recommended BP therapy continue to progress during the long term.

Author Affiliations: Welch Center for Prevention, Epidemiology, and Clinical Research, The Johns Hopkins institutions, Baltimore (Dr Appel and Ms Charleston), and Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda (Drs Kusek and Agodoa), Maryland; Department of Medicine, Case Western Reserve University (Drs Wright and Rahman) and Department of Quantitative Health Sciences, Cleveland Clinic Foundation (Drs Wang and Gassman), Cleveland, Ohio; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City (Dr Greene); Division of Nephrology, Vanderbilt Medical Center, Nashville, Tennessee (Drs Lewis and Schulman); Nephrology Division, Department of Medicine, Lenox Hill–Mount Sinai School of Medicine, New York, New York (Dr Lipkowitz); Department of Medicine, Martin Luther King, Jr/Charles R. Drew University of Medicine and Science (Dr Norris) and Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center (Dr Kopple), Los Angeles, and Department of Medicine, University of California at San Diego (Dr Gabbai); Department of Medicine, University of Chicago School of Medicine, Chicago, Illinois (Dr Bakris); Department of Medicine, University of Miami, Miami, Florida (Dr Contreras); and Department of Medicine, University of Alabama at Birmingham (Dr Rostand).

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