The edition · Nephrology
Driving blood pressure below 140 after thrombectomy costs kidneys
A secondary analysis of OPTIMAL-BP links intensive post-thrombectomy blood pressure lowering to more than double the acute kidney injury, KDIGO comments on where three newly approved IgA nephropathy drugs fit, and SGLT2 inhibitors still have no established benefit in polycystic kidney disease.
The edition in brief
A secondary analysis of the OPTIMAL-BP trial examined 287 patients who achieved successful endovascular thrombectomy for large-vessel-occlusion stroke and had a systolic pressure of 140 mmHg or above, randomised to intensive (below 140) or conventional (140 to 180) blood pressure targets for 24 hours. Acute kidney injury within 7 days occurred in 13.6% of the intensive group against 6.4% of the conventional group (adjusted odds ratio 2.54, 95% CI 1.10 to 6.35). Most events were stage 1. Patients who developed acute kidney injury had far worse outcomes — functional independence at 3 months in 13.8% against 49.0%, and stroke-related mortality 37.9% against 3.1%. A sensitivity analysis with equal creatinine ascertainment did not reach significance, which matters. KDIGO has issued a commentary rather than a full guideline update on IgA nephropathy, after three further treatments received accelerated FDA approval following the 2025 guideline revision. Two of the three work through mechanisms different from previously approved drugs, and the work group sets out provisionally where they fit pending more evidence. An individual participant data meta-analysis of CANVAS and CREDENCE covering 7,990 participants aged 50 or over found canagliflozin reduced end-stage kidney disease by 46.5% (pooled hazard ratio 0.535, 95% CI 0.392 to 0.729), with a number needed to treat of 27.5 over three years in CREDENCE. Cardiovascular mortality favoured canagliflozin but did not reach significance. A meta-analysis of six studies and 451 patients found no established benefit of SGLT2 inhibitors on kidney outcomes in autosomal dominant polycystic kidney disease. Today's pearl: an eGFR fall after starting an SGLT2 inhibitor is expected, and stopping the drug is usually the error.
Post-thrombectomy blood pressure targets: the kidney pays for the extra 20 mmHg
Keep the systolic target at 140 to 180 mmHg after successful thrombectomy — driving below 140 more than doubled acute kidney injury, and those patients did far worse neurologically.
KDIGO comments on where three new IgA nephropathy drugs fit
Three new IgA nephropathy drugs now have accelerated approval; KDIGO's commentary positions them provisionally, and the sequencing rule is to exhaust supportive care, RAS blockade and SGLT2 inhibition first.
Canagliflozin in older adults: a 27-patient number needed to treat for end-stage kidney disease
In adults over 50 with albuminuric diabetic kidney disease, canagliflozin prevents one case of end-stage kidney disease for about every 27 patients treated over three years.
The eGFR dip after starting an SGLT2 inhibitor is the drug working
Tell patients and colleagues in advance that eGFR falls after starting an SGLT2 inhibitor — a dip of up to about 30% is the mechanism working and is not a reason to stop.
SGLT2 inhibitors in polycystic kidney disease: still no established benefit
SGLT2 inhibitors have no established kidney benefit in autosomal dominant polycystic kidney disease — prescribe them only where there is a separate indication.
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