Should we shift toward higher blood pressure targets in patients with chronic kidney disease?

Hypertension is the leading cause of death worldwide and is responsible for a significantly increased burden of cardiovascular events and progression to end-stage kidney disease in patients with chronic kidney disease (CKD). The fundamentals of therapeutics in patients with hypertension and CKD are both the use of specific renal protecting agents and the achievement of tight blood pressure control - i.e., blood pressure values below 130/80 mm Hg. When the evidence underpinning a "tight blood pressure target control" recommendation is analyzed, hypertension guidelines appear to be largely extrapolating to people with CKD the key findings of large trials conducted in the general population and other high cardiovascular risk populations, while renal societies guidelines are primarily influenced by observational data reporting renal outcomes and small-scale randomized studies, and have not always incorporated recent evidence from systematic reviews. In this narrative review, we present existing guidelines and evidence for 2 crucial clinical questions in the management of hypertension of CKD: (i) should we, and by how much should we, lower blood pressure in people with CKD and (ii) are there agents which are specifically beneficial in the CKD population, independent of blood pressure control.