participants with CKD by tertile of baseline diastolic BP Adverse Event Type Lowest tertile ,69 mm Hg Middle tertile 569–79 mm Hg Highest tertile $80 mm Hg Any serious adverse eventa Incidence rate Intensive 24.3 (223/919) 21.6 95% CI, 95% confidence interval. a Models adjusted for age, sex, race, cardiovascular disease, Framingham 10-year cardiovascular disease risk score $15%, smoking history, and baseline eGFR. Likelihood ratio tests comparing HRs for the systolic BP intervention among baseline diastolic BP tertiles were nonsignificant. KIDNEY360 1: 368–375, May, 2020 Diastolic Blood Pressure in SPRINT CKD, Chang et al. 373 Our analysis has several strengths, including the inclusion of patients with CKD in the SPRINT as a prespecified subgroup and the randomized allocation to an intensive or standard SBP treatment target. Observational analyses that rely on examination of achieved DBP can lead to different inferences due at least in part to confounding of achieved BP by differences in disease severity and adherence (14). However, our analysis also has some limitations. First, although the SPRINT represents the largest BP intervention trial in CKD to date, it was not designed to detect interaction by baseline DBP in the CKD subgroup, and thus, we may have lacked the power to detect a statistically significant interaction. Second, although our cohort was diverse in terms of age, sex, race, and inclusion of patients with baseline heart disease, the study excluded patients with diabetes mellitus or history of stroke, which may limit the generalizability of our findings to those important patient populations. In addition, the SPRINT enrolled relatively few patients with stage 3b or higher CKD and excluded patients with .1 g of proteinuria per day. Because the efficacy and safety of intensive BP lowering may differ in patients with more advanced (stage 4/5) CKD, future BP intervention studies dedicated to enrolling this patient population specifically are needed. In summary, patients with mild to moderate CKD are at high risk for cardiovascular events and death. In SPRINT participants with CKD at baseline, lower DBP was associated with higher rates of the primary composite end point and all-cause death as well as higher rates of serious adverse events, including hypotension, syncope, electrolyte abnormalities, and AKI, in an observational on-treatment analysis. However, in randomized comparisons, lower baseline levels of DBP did not modify the beneficial effect of the intensive SBP intervention on the primary outcome and allcause death. Our results suggest that lower DBP should not necessarily be a barrier to more intensive SBP lowering in patients with mild to moderate CKD. Careful treatment and follow-up are essential in all patients with CKD, especially patients with more advanced disease. Acknowledgments The Systolic Blood Pressure Intervention Trial (SPRINT) investigators acknowledge the contribution of study medications (azilsartan and azilsartan combined with chlorthalidone) from Takeda Pharmaceuticals International, Inc. All components of the SPRINT study protocol were designed and implemented by the investigators. The investigative team collected, analyzed, and interpreted the data. All aspects of manuscript writing and revision were carried out by the coauthors. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the US Department of Veterans Affairs, or the US Government. This manuscript was prepared using SPRINT Primary Outcome Paper Data (SPRINT-POP) Research Materials obtained from the National Heart, Lung, and Blood Institute (NHLBI) Biologic Specimen and Data Repository Information Coordinating Center and does not necessarily reflect the opinions or views of the SPRINT_POP or the NHLBI. All authors are SPRINT investigators. This manuscript was prepared using SPRINT data obtained from the NHLBI Biologic Specimen and Data Repository Information Coordinating Center. The views expressed in this paper are those of the authors and do not represent the official position of the National Institutes of Health, the Department of Veterans Affairs, the US Government, or the SPRINT Research Group. This paper was approved by the SPRINT Publications and Presentations Committee. Author Contributions S. Beddhu, R. Boucher, T. I. Chang, T. Greene, and G. Wei conceptualized the study; S. Beddhu and T. I. Chang were responsible for investigation; S. Beddhu, R. Boucher, T. I. Chang, and G. Wei were responsible for methodology; S. Beddhu, T. I. Chang, and T. Greene provided supervision; S. Beddhu and T. I. Chang wrote the original draft; R. Boucher and G. Wei were responsible for data curation; G. Wei was responsible for formal analysis; S. Beddhu and G. Wei were responsible for software; S. Beddhu, T. Greene, and G. Wei were responsible for validation; T.I. Chang, S. Beddhu, and T. Greene were responsible for project administration; S. Beddhu was responsible for funding acquisition and resources; and S. Beddhu, R. Boucher, T. I. Chang, G. M. Chertow, A. K. Cheung, T. Greene, H. Kramer, G. Wei, and P. K. Whelton reviewed and edited the manuscript. Disclosures S. Beddhu reports grants from NHLBI and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), during the conduct of the study,