Blood-pressure lowering helps across kidney disease stages Lowering blood pressure reduced major heart and stroke events similarly in people with and without chronic kidney disease.
*Individual-participant meta-analysis of randomized trials; Level 1a (OCEBM).

Citation

Zeng G, Bidel Z, Yang Q, et al. Pharmacological blood-pressure lowering for the prevention of cardiovascular disease and death across the full spectrum of chronic kidney disease severity: an individual-participant data meta-analysis. Lancet. 2026;407:1626–1638.

Background

People with more severe chronic kidney disease have often been left out of blood-pressure drug trials, leaving uncertainty about heart and stroke prevention across kidney disease stages.

Patients

285,124 adults from 46 randomized trials (59,185 with chronic kidney disease at baseline). Excluded: unclear randomization, trials limited to heart failure or acute-care settings, prior heart failure, and extreme creatinine values.

Intervention

Blood-pressure-lowering drug therapy (or more intensive regimen), standardized to a 5 mm Hg lowering in systolic blood pressure.

Control

Placebo, less intensive therapy, or comparator regimen.

Outcome

(Primary) Major cardiovascular events: stroke, ischemic heart disease, or hospitalization for (or death from) heart failure.

Follow-up Period

Median 4.4 years.

Results

Group Effect on major cardiovascular events (hazard ratio)
With chronic kidney disease 0.91 (0.87–0.94)
Without chronic kidney disease 0.90 (0.88–0.93)
Chronic kidney disease, no diabetes 0.88 (0.84–0.93)
Chronic kidney disease, with diabetes —

Hazard ratio: values below 1.0 mean fewer events in the treated group. “—” indicates no clear difference.

Analyses were intention-to-treat. Benefits were consistent across kidney disease stages and baseline blood-pressure levels, including below 120/70 mm Hg.

Limitations

This analysis focused on heart and death outcomes, not treatment harms (such as kidney injury, high potassium, or fainting). Fewer participants had very advanced kidney disease, making estimates less certain there. Protein-in-urine results were available only in some trials. The smaller relative benefit in people with both chronic kidney disease and diabetes may limit how strongly results apply to that subgroup.

Funding

British Heart Foundation; funder had no role in analyses.

Clinical Application

Use blood-pressure-lowering drugs for cardiovascular prevention at any chronic kidney disease stage; expect similar relative benefit, but monitor harms and note weaker benefit in those with diabetes.