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Relationship between ambulatory BP and clinical outcomes in patients with hypertensive CKD.

ABSTRACT: BACKGROUND AND OBJECTIVES:Abnormal ambulatory BP (ABP) profiles are commonplace in CKD, yet the prognostic value of ABP for renal and cardiovascular outcomes is uncertain. This study assessed the relationship of baseline ABP profiles with CKD progression and subsequent cardiovascular outcomes to determine the prognostic value of ABP beyond that of clinic BP measurements. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:Between 2002 and 2003, 617 African Americans with hypertensive CKD treated to a clinic BP goal of <130/80 mmHg were enrolled in this prospective, observational study. Participants were followed for a median of 5 years. Primary renal outcome was a composite of doubling of serum creatinine, ESRD, or death. The primary cardiovascular outcome was a composite of myocardial infarction, hospitalized congestive heart failure, stroke, revascularization procedures, cardiovascular death, and ESRD. RESULTS:Multivariable Cox proportional hazard analysis showed that higher 24-hour systolic BP (SBP), daytime, night-time, and clinic SBP were each associated with subsequent renal (hazard ratio, 1.17-1.28; P<0.001) and cardiovascular outcomes (hazard ratio, 1.22-1.32; P<0.001). After controlling for clinic SBP, ABP measures were predictive of renal outcomes in participants with clinic SBP <130 mmHg (P<0.05 for interaction). ABP predicted cardiovascular outcomes with no interaction based on clinic BP control. CONCLUSIONS:ABP provides additional information beyond that of multiple clinic BP measures in predicting renal and cardiovascular outcomes in African Americans with hypertensive CKD. The primary utility of ABP in these CKD patients was to identify high-risk individuals among those patients with controlled clinic BP.

SUBMITTER: Gabbai FB

PROVIDER: S-EPMC3488952 | biostudies-literature | 2012 Nov

REPOSITORIES: biostudies-literature

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Relationship between ambulatory BP and clinical outcomes in patients with hypertensive CKD.

Gabbai Francis B FB Rahman Mahboob M Hu Bo B Appel Lawrence J LJ Charleston Jeanne J Contreras Gabriel G Faulkner Marquetta L ML Hiremath Leena L Jamerson Kenneth A KA Lea Janice P JP Lipkowitz Michael S MS Pogue Velvie A VA Rostand Stephen G SG Smogorzewski Miroslaw J MJ Wright Jackson T JT Greene Tom T Gassman Jennifer J Wang Xuelei X Phillips Robert A RA

Clinical journal of the American Society of Nephrology : CJASN 20120830 11

<h4>Background and objectives</h4>Abnormal ambulatory BP (ABP) profiles are commonplace in CKD, yet the prognostic value of ABP for renal and cardiovascular outcomes is uncertain. This study assessed the relationship of baseline ABP profiles with CKD progression and subsequent cardiovascular outcomes to determine the prognostic value of ABP beyond that of clinic BP measurements.<h4>Design, setting, participants, & measurements</h4>Between 2002 and 2003, 617 African Americans with hypertensive CK ...[more]

PMID: 22935847

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Project description:Background and objectivesHypertension is the most important treatable risk factor for cardiovascular outcomes. Many patients with CKD are elderly, but the ideal BP in these individuals is unknown.Design, setting, participants, & measurementsFrom among 339,887 patients with incident eGFR<60 ml/min per 1.73 m(2), we examined associations of systolic BP (SBP) and diastolic BP (DBP) with all-cause mortality, incident coronary heart disease (CHD), ischemic strokes, and ESRD from the time of developing CKD until the end of follow-up (July 26, 2013, for mortality, CHD, and stroke, and December 31, 2011, for ESRD) in multivariable-adjusted survival models categorized by patients' age.ResultsOf the total cohort, 300,424 (88%) had complete data for multivariable analysis. Both SBP and DBP showed a U-shaped association with mortality. SBP displayed a linear association with CHD, stroke, and ESRD, whereas DBP showed no consistent association with either. SBP>140 mmHg was associated with higher incidence of all examined outcomes, but with an incremental attenuation of the observed risk in older compared with younger patients (P<0.05 for interaction) The adjusted hazard ratios and 95% confidence intervals associated with SBP?170 mmHg (compared with 130-139 mmHg) in patients <50, 50-59, 60-69, 70-79, and ?80 years were 1.95 (1.34 to 2.84), 2.01 (1.75 to 2.30), 1.68 (1.49 to 1.89), 1.39 (1.25 to 1.54), and 1.30 (1.17 to 1.44), respectively. The risk of incident CHD, stroke, and ESRD was incrementally higher with higher SBP in patients aged <80 years but showed no consistent association in those aged ?80 years (P<0.05 for interaction for all outcomes).ConclusionsIn veterans with incident CKD, SBP showed different associations in older versus younger patients. The association of higher SBP with adverse outcomes was present but markedly reduced in older individuals, especially in those aged ?80 years. Elevated DBP showed no consistent association with vascular outcomes in patients with incident CKD.

Project description:Complications of hypertension are particularly common in people of African descent but previous reports had suggested rarity of hypertensive retinopathy in black Africans. We evaluated retinal changes among Nigerian hypertensive patients and determined their relationship with renal function.Consecutive Hypertensive patients who were ≥18 years were selected for the study. Socio-demographic characteristics, anthropometric parameters and blood pressure were measured. All patients had ophthalmoscopic examination and retinal changes were graded according to Keith-Wegener's classification. Blood samples were taken for blood urea nitrogen, lipids and C-reactive protein; and urine was collected for creatinine and microalbuminuria. Serum creatinine was determined using modified Jaffe method and estimated glomerular filtration (eGFR) was calculated using MDRD equation: 186 × (Creatinine/88.4)-1.154 × (Age)-0.203 × (0.742 if female) × (1.210 if black).Of the 240 patients studied, 187 (78 %) had one form of retinopathy or the other. While 85 (35.4 %) patients had grade 1 retinopathy, 87 (36.3 %) had grade 2, 13 (5.4 %) had grade 3 and 2 (0.83 %) had grade 4 respectively. Comparison of patients with and without retinopathy showed that, the former were older (p = 0.001) and had longer duration of hypertension (p = 0.001). Similarly, hypertensive patients with retinopathy had higher total cholesterol and low density lipoprotein cholesterol (p = 0.017, p = 0.041 respectively). However, eGFR was lower in individuals with retinopathy (46.2 ml/min/1.73) than those with normal retinal (55.9 ml/min/1.73) findings, p = 0.019. Multi-variable adjusted odds ratios showed increased probability of retinopathy with age (odds ratio-1.08, p = 0.001) and body mass index (odds ratio-1.20, p = 0.013).Hypertensive retinopathy is a common clinical finding among hypertensive Nigerians and may occur pari passu with renal damage as consequences of long standing hypertension.

Project description:BackgroundWhether ambulatory BP monitoring is of value in evaluating risk for outcomes in patients with CKD is not clear.MethodsWe followed 1502 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study for a mean of 6.72 years. We evaluated, as exposures, ambulatory BP monitoring profiles (masked uncontrolled hypertension, white-coat effect, sustained hypertension, and controlled BP), mean ambulatory BP monitoring and clinic BPs, and diurnal variation in BP-reverse dipper (higher at nighttime), nondipper, and dipper (lower at nighttime). Outcomes included cardiovascular disease (a composite of myocardial infarction, cerebrovascular accident, heart failure, and peripheral arterial disease), kidney disease (a composite of ESKD or halving of the eGFR), and mortality.ResultsCompared with having controlled BP, the presence of masked uncontrolled hypertension independently associated with higher risk of the cardiovascular outcome and the kidney outcome, but not with all-cause mortality. Higher mean 24-hour systolic BP associated with higher risk of cardiovascular outcome, kidney outcome, and mortality, independent of clinic BP. Participants with the reverse-dipper profile of diurnal BP variation were at higher risk of the kidney outcome.ConclusionsIn this cohort of participants with CKD, BP metrics derived from ambulatory BP monitoring are associated with cardiovascular outcomes, kidney outcomes, and mortality, independent of clinic BP. Masked uncontrolled hypertension and mean 24-hour BP associated with high risk of cardiovascular disease and progression of kidney disease. Alterations of diurnal variation in BP are associated with high risk of progression of kidney disease, stroke, and peripheral arterial disease. These data support the wider use of ambulatory BP monitoring in the evaluation of hypertension in patients with CKD.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2020_09_24_JASN2020030236.mp3.

Project description:Rationale & objectiveItching is a frequent symptom experienced by people with chronic kidney disease (CKD). We investigated the associations of CKD-associated pruritus (CKD-aP) with clinical outcomes.Study designThis was a longitudinal cohort study.Setting & participantsPatients from Brazil, France, and the United States enrolled in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) from 2013 to 2021, an international prospective cohort study of adults with nondialysis dependent CKD, and an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2 were included.ExposureCKD-aP was self-reported by response to the question: "During the past 4 weeks, to what extent were you bothered by itchy skin?"OutcomesThe outcomes were as follows: CKD progression, kidney replacement therapy (KRT) initiation, mortality, hospitalization, cardiovascular events, infection events.Analytical approachAssociations with time-to-event outcomes were investigated using Cox proportional hazards models adjusted for potential confounders.ResultsThere were 4,410 patients from 91 clinics with a median age of 69 years and a median eGFR at patient questionnaire completion of 29 (21-38) mL/min/1.73 m2. The proportion of patients not at all, somewhat, moderately, very much, and extremely bothered by itchy skin was 49%, 27%, 13%, 7%, and 3%, respectively. Patients with more advanced stages of CKD, older age, and greater comorbidities reported to be more likely bothered by itchy skin. Among patients at least moderately bothered, 23% were prescribed at least 1 pharmacotherapy (35% in the United States, 19% in France, 4% in Brazil), including antihistamine (10%), gabapentin (6%), topical corticosteroids (4%), pregabalin (3%), or sedating antihistamine (3%). The HR (95% CI) for patients extremely (vs not at all) bothered was 1.74 (1.11-2.73) for all-cause mortality, 1.56 (1.11-2.18) for all-cause hospitalization, and 1.84 (1.22-2.75) for cardiovascular events. As CKD-aP severity increased, patients also had higher rates of infection events (P = 0.04); CKD-aP severity was not associated with KRT initiation (P = 0.20) or CKD progression (P = 0.87).LimitationsThe limitations were 25% nonresponse rate, recall bias, and residual confounding factors.ConclusionsThese results demonstrate a strong association between severe itch and clinical outcomes, providing the nephrology community new insights into the possible adverse consequences of CKD-aP in individuals with nondialysis CKD, and warrant further exploration.Plain-language summaryChronic kidney disease-associated pruritus (CKD-aP) is a common disturbing symptom of chronic kidney disease (CKD). This article analyzes longitudinal data from the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) to describe prevalence of CKD-aP in 4,410 individuals with nondialysis CKD, and its association with clinical outcomes. We found that 51% of the surveyed population were bothered by pruritus. CKD-aP was more prevalent in those with more advanced stages of CKD, older age, and with more comorbid conditions. Compared to those not at all bothered by pruritus, those who were extremely bothered had a higher risk of all-cause mortality, hospitalizations, and cardiovascular events. Severity of CKD-aP was not associated with CKD progression or initiation of kidney replacement therapy.

Project description:BACKGROUND AND OBJECTIVES:In the Systolic Blood Pressure Intervention Trial (SPRINT), intensive systolic BP treatment (target <120 mm Hg) was associated with fewer cardiovascular events and higher incidence of kidney function decline compared with standard treatment (target <140 mm Hg). We evaluated the association between mean arterial pressure reduction, kidney function decline, and cardiovascular events in patients without CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:We categorized patients in the intensive treatment group of the SPRINT according to mean arterial pressure reduction throughout follow-up: <20, 20 to <40, and ?40 mm Hg. We defined the primary outcome as kidney function decline (?30% reduction in eGFR to <60 ml/min per 1.73 m2 on two consecutive determinations at 3-month intervals), and we defined the secondary outcome as cardiovascular events. In a propensity score analysis, patients in each mean arterial pressure reduction category from the intensive treatment group were matched with patients from the standard treatment group to calculate the number needed to treat regarding cardiovascular events and the number needed to harm regarding kidney function decline. RESULTS:In the intensive treatment group, 1138 (34%) patients attained mean arterial pressure reduction <20 mm Hg, 1857 (56%) attained 20 to <40 mm Hg, and 309 (9%) attained ?40 mm Hg. Adjusted hazard ratios for kidney function decline were 2.10 (95% confidence interval, 1.22 to 3.59) for mean arterial pressure reduction between 20 and 40 mm Hg and 6.22 (95% confidence interval, 2.75 to 14.08) for mean arterial pressure reduction ?40 mm Hg. In propensity score analysis, mean arterial pressure reduction <20 mm Hg presented a number needed to treat of 44 and a number needed to harm of 65, reduction between 20 and <40 mm Hg presented a number needed to treat of 42 and a number needed to harm of 35, and reduction ?40 mm Hg presented a number needed to treat of 95 and a number needed to harm of 16. CONCLUSIONS:In the intensive treatment group of SPRINT, larger declines in mean arterial pressure were associated with higher incidence of kidney function decline. Intensive treatment seemed to be less favorable when a larger reduction in mean arterial pressure was needed to attain the BP target.

Dataset Information

Relationship between ambulatory BP and clinical outcomes in patients with hypertensive CKD.

Publications

Relationship between ambulatory BP and clinical outcomes in patients with hypertensive CKD.

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