An analysis of >2,500 patients from the SPS3 randomized trial who experienced a lacunar stroke but maintained kidney function has found that intensive blood pressure (BP) lowering (<130 mmHg) is associated with an increased risk of accelerated decline in renal function compared to standard BP control (130–140 mmHg). Peralta et al. observed that the rate of estimated glomerular filtration rate decline was fastest during the first year of anti-hypertensive treatment, affecting 24% of those in the intensive BP group compared to 19% in the standard BP group. This rapid decline was not associated with a higher risk of clinical events in the intensive BP group.