Abstract
This systematic review evaluates the renal implications of intensive versus standard blood pressure (BP) control in patients with chronic kidney disease (CKD). PubMed, Scopus, and Embase were searched through June 2025 for randomized controlled trials (RCTs) and high-quality post hoc analyses comparing intensive (systolic BP <120 mmHg) versus standard targets (<140 mmHg) in adults with CKD. Four studies involving 20,803 participants with a median follow-up of 2 to 3.2 years were included. Intensive BP control was associated with a higher incidence of ≥40% estimated glomerular filtration rate (eGFR) decline in non-albuminuric patients (hazard ratio up to ~4.5), but showed a significant reduction in proteinuria among patients with diabetic nephropathy (mean reduction ~1,200 mg/24h). Across all studies, the cardiovascular benefits of intensive BP lowering were consistent regardless of baseline kidney function. Overall, intensive BP control does not cause long-term renal harm, though early eGFR decline may reflect hemodynamic rather than structural changes. Patients with albuminuria appear to gain the most renal benefit, supporting individualized BP targets. Clinically, tailoring BP goals to albuminuria status may optimize renal outcomes while maintaining cardiovascular protection.