Peterson JC, Adler S, Burkart JM, Greene T, Heert LA, Hunsicker LG et al (MDRD Study Group)
Blood pressure control, proteinuria and the progression of renal disease

Ann Int Med (Nov) 123:754-762 1995

The optimal BP control for preventing target organ damage in hypertension is a major issue in clinical medicine. Likewise, the optimal BP level for slowing the rate of progression of any form of renal disease has not been clearly defined. The modification of diet in renal disease (MDRD) study was designed to focus on the effect of dietary protein restriction on progression of renal disease. However, it was also designed to determine (perhaps more importantly) the effect of BP control on the progression of renal disease. In this paper, the authors looked carefully at the relationship between decline in GFR, proteinuria and achieved BP during follow-up. In this important analysis of patients with GFR values ranging from 25-55 (Study A) and 13-24 (Study B), the authors found that GFR declined faster in patients with higher BP levels. More importantly, they found that in patients with higher grade proteinuria, lowering mean arterial pressure to < 92 mmHg slowed the rate of decline in GFR to a significantly greater extent than lowering mean arterial pressure to 107 mmHg. Importantly, they found that there was no difference in the decline in GFR in patients with a baseline urine protein excretion rate < 0.25 g/d regardless of BP control level. However, their data indicate that patients with this level of proteinuria have very slow rate of decline in GFR. This was true in patients in both Study A and B. Also, they found that lower achieved BP was associated with a greater and more sustained lowering of proteinuria over time. Finally, it was shown that lowering proteinuria during the first 4 months of follow-up was associated with a slower rate of decline in GFR after 4 months of follow-up. These new data in a large cohort of patients with chronic renal insufficiency are consistent with the view that proteinuria may be an independent risk factor for progressive renal disease.

Comment: These findings have important practice implications for internists and nephrologists. The data strongly suggest that patients with > 1.0 g/d of proteinuria should have MAP lowered to the level of 92 mm Hg and for patients with proteinuria in the range of 0.25 to 1.0 g/day MAP should be controlled to a level of about 98 mm Hg. (Toto)

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H: Pathophysiology : Kidney in hypertension
CRF by problem area : Progression

, -Saturday, September 20, 1997 at 09:17:10 (PDT)