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Intensive Blood Pressure Control Slows Progression of Chronic Kidney Disease in Children

The renoprotective effect of blood pressure control is independent of ACE inhibition.

Hypertension and an unregulated renin-angiotensin system have known adverse effects on progression of chronic kidney disease in adults, but data in children are lacking. In an international study, researchers randomized 385 children (age range, 3–18 years) with chronic kidney disease to intensive blood pressure (BP) control (24-hour mean arterial pressure <50th percentile for age) or standard BP control (mean arterial pressure, 50th to 95th percentile) using a fixed high dose of the angiotensin-converting–enzyme (ACE) inhibitor ramipril (6 mg/m² body surface daily) plus additional antihypertensives, if needed.

After 5 years, significantly fewer children in the intensive BP-control group than in the standard BP-control group reached the primary endpoint of 50% decline in glomerular filtration rate (GFR) or progression to end-stage renal disease (30% vs. 42%; hazard ratio, 0.65). The renoprotective effect of intensive BP control persisted after adjustment for covariates and was greater in children with glomerulopathies than in children with hypoplasia-dysplasia renal disease. In both groups, mean proteinuria decreased during the first 6 months but, despite good BP control, gradually returned to baseline levels during the following 36 months.

Comment: This important study demonstrates that aggressive BP control, targeted lower than the 50th percentile for age, slows progression of chronic kidney disease in children and that the benefit seems to be independent of ACE inhibition. Unique limitations of the study include use of a fixed dose of ACE inhibitor in both groups and a somewhat imprecise formula-based (vs. direct) measure of GFR. Escape from the antiproteinuric effect of ACE inhibition in children is a new finding and might lead to additional insights for treating children with chronic kidney disease.

— F. Bruder Stapleton, MD

Published in Journal Watch Pediatrics and Adolescent Medicine October 21, 2009

Citation(s):

The ESCAPE Trial Group. Strict blood-pressure control and progression of renal failure in children. N Engl J Med 2009 Oct 22; 361:1639.

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• Medline abstract (Free)

Ingelfinger JR. Blood-pressure control and delay in progression of kidney disease in children. N Engl J Med 2009 Oct 22; 361:1701.

• Original article (Subscription may be required)
• Medline abstract (Free)