Blood Pressure Variability, Mortality, and Cardiovascular Outcomes in CKD Patients.
Clinical journal of the American Society of Nephrology : CJASN
BACKGROUND AND OBJECTIVES:Short-term BP variability (derived from 24-hour ambulatory BP monitoring) and long-term BP variability (from clinic visit to clinic visit) are directly related to risk for cardiovascular events, but these relationships have been scarcely investigated in patients with CKD, and their prognostic value in this population is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:In a cohort of 402 patients with CKD, we assessed associations of short- and long-term systolic BP variability with a composite end point of death or cardiovascular event. Variability was defined as the standard deviation of observed BP measurements. We further tested the prognostic value of these parameters for risk discrimination and reclassification. RESULTS:Mean ± SD short-term systolic BP variability was 12.6±3.3 mm Hg, and mean ± SD long-term systolic BP variability was 12.7±5.1 mm Hg. For short-term BP variability, 125 participants experienced the composite end point over a median follow-up of 4.8 years (interquartile range, 2.3-8.6 years). For long-term BP variability, 110 participants experienced the composite end point over a median follow-up of 3.2 years (interquartile range, 1.0-7.5 years). In adjusted analyses, long-term BP variability was significantly associated with the composite end point (hazard ratio, 1.24; 95% confidence interval, 1.01 to 1.51 per 5-mm Hg higher SD of office systolic BP), but short-term systolic BP variability was not (hazard ratio, 0.92; 95% confidence interval, 0.68 to 1.25 per 5-mm Hg higher SD of 24-hour ambulatory systolic BP). Neither estimate of BP variability improved risk discrimination or reclassification compared with a simple risk prediction model. CONCLUSIONS:In patients with CKD, long-term but not short-term systolic BP variability is related to the risk of death and cardiovascular events. However, BP variability has a limited role for prediction in CKD.
10.2215/CJN.04030318
Vascular calcification is associated with Wnt-signaling pathway and blood pressure variability in chronic kidney disease rats.
Liao Ruoxi,Wang Liya,Li Jiameng,Sun Si,Xiong Yuqin,Li Yupei,Han Mei,Jiang Heng,Anil Mahajan,Su Baihai
Nephrology (Carlton, Vic.)
AIM:Vascular calcification (VC) is a common complication in chronic kidney disease (CKD) and has been shown to be associated with increased cardiovascular events and mortality. This study was to explore the role of Wnt-signaling pathway in CKD VC, and the association between VC and blood pressure variability (BPV) which is a risk factor of cardiovascular events. METHODS:Adult male Sprague-Dawley rats were divided into adenine-induced CKD group (n = 5), 5/6 nephrectomy CKD group (n = 5), sham group (n = 5) and control group (n = 5). Low-calcium-high-phosphate diets were introduced to induce vascular calcification. Both daytime (hour-to-hour during the day) and mid-term (day-to-day for 9 days) blood pressure (BP) were collected and analyzed for BPV metrics. At sacrifice, kidney, heart and aorta samples were taken for histological analyses. Calcium deposition in aorta was identified with Alizarin Red stain and graded. Immunohistochemistry stain and western blot were performed for Wnt3a, Wnt5a, β-catenin, sclerostin, osteopontin, and α-SMA. RESULTS:Compared with control rats, CKD rats suffered from markedly severer VC (Grade 2.6 ± 0.2 and 1.8 ± 0.8 vs 0.0 ± 0.0 and 0.2 ± 0.4, P = .0010). VC was positively correlated with vascular Wnt3a and β-catenin expression (P = .0032 and .0000), but not significantly associated with Wnta5a or sclerostin. Besides, CKD rats showed increased BPV (P < .001), which was also positively correlated with VC. CONCLUSION:We confirmed that CKD rats had enhanced Wnt-signaling in vascular tissue and severer aorta calcification together with increased BPV. Wnt pathway may be a potential target in future VC and BPV management in CKD.
10.1111/nep.13677
Short-Term Systolic Blood Pressure Variability and Kidney Disease Progression in Patients With Chronic Kidney Disease: Results From C-STRIDE.
Wang Qin,Wang Yu,Wang Jinwei,Zhang Luxia,Zhao Ming-Hui,
Journal of the American Heart Association
Background It is unclear whether short-term blood pressure variability is associated with renal outcomes in patients with chronic kidney disease. Methods and Results This study analyzed data from participants in the C-STRIDE (Chinese Cohort Study of Chronic Kidney Disease) who had chronic kidney disease stages 1 to 4. Short-term blood pressure variability was measured by calculating the weighted SD (w-SD) of systolic blood pressure (SBP). Renal outcomes were defined as dialysis initiation and/or transplantation. Risk factors associated with w-SD of SBP were evaluated by linear regression. Associations of short-term SBP variability with renal outcomes were evaluated by Cox regression. In total, 1421 patients with chronic kidney disease were included in this study (mean age, 49.4±13.6 years; 56.2% men; estimated glomerular filtration rate, 50.5±29.3 mL/min per 1.73 m; proteinuria, 0.9 [0.3-2.0] g/d). Mean w-SD of SBP was 12.6±4.4 mm Hg. w-SD of SBP was independently associated with older age, 24-hour SBP, blood pressure circadian pattern, and angiotensin II receptor blocker treatment. During a median follow-up of 4.9 years, 237 patients developed renal outcomes (37.01 per 1000 patient-years). The incidence rate increased across the quartiles of w-SD (log-rank =0.005). w-SD of SBP was associated with an increased risk of renal outcomes, both as a continuous variable (hazard ratio [HR], 1.47; 95% CI, 1.09-1.99) and as a categorical variable (quartile 4 versus quartile 1: HR, 1.60; 95% CI, 1.08-2.36), independent of 24-hour SBP, daytime SBP, and nighttime SBP. Conclusions Short-term SBP was independently associated with the risk of dialysis initiation and/or transplantation in patients with chronic kidney disease.
10.1161/JAHA.120.015359
Visit-to-visit variability in blood pressure and the development of chronic kidney disease in treated general hypertensive patients.
Li Youbao,Li Dan,Song Yun,Gao Lan,Fan Fangfang,Wang Binyan,Liang Min,Wang Guobao,Li Jianping,Zhang Yan,Xu Xin,Hou Fan Fan,Cheng Xiaoshu,Sun Ningling,Sun Yingxian,Zhao Lianyou,Wan Qijun,Li Xiaoming,Li Junnong,Han Qinghua,Xu Xiping,Huo Yong,Qin Xianhui
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association
BACKGROUND:Data on the association between visit-to-visit variability (VVV) in blood pressure (BP) and the risk of chronic kidney disease (CKD) in general treated hypertensive patients were limited. We aimed to evaluate the relation of VVV in BP with the development of CKD, and examine any possible effect modifiers in hypertensive patients without prior cardiovascular diseases (CVDs) or CKD. METHODS:This is a post hoc analysis of the Renal Sub-study of the China Stroke Primary Prevention Trial (CSPPT). A total of 10 051 hypertensives without CVD and CKD and with at least six visits of BP measurements from randomization to the 24-month visit were included. The main VVV in BP was expressed as standard deviation (SD). The primary outcome was the development of CKD, defined as a decrease in estimated glomerular filtration rate ≥30% and to a level of <60 mL/min/1.73 m2, or end-stage renal disease. RESULTS:The median treatment duration was 4.4 years. After multivariable adjustment, including baseline systolic blood pressure (SBP) and mean SBP during the first 2-year treatment period, there was a significantly positive relationship of SD of SBP with the risk of CKD development (per SD increment; odds ratio, 1.27; 95% confidence interval: 1.10-1.46). The results were similar for coefficient of variation (CV) of SBP. Results across various subgroups, including age, sex, SBP at baseline, treatment compliance, concomitant antihypertensive medications and mean SBP during the first 24-month treatment period, were consistent. CONCLUSIONS:SBP variability, irrespective of mean BP level, was significantly associated with the development of CKD in general treated hypertensive patients.
10.1093/ndt/gfz093
Ambulatory blood pressure variability and risk of cardiovascular events, all-cause mortality, and progression of kidney disease.
Jhee Jong Hyun,Seo Jiwon,Lee Chan Joo,Park Jung Tak,Han Seung Hyeok,Kang Shin-Wook,Park Sungha,Yoo Tae-Hyun
Journal of hypertension
BACKGROUND:Association between blood pressure (BP) variability and cardiovascular outcome remains unclear in patients with chronic kidney disease (CKD). We evaluated this association between ambulatory BP variability and cardiovascular events, mortality, and kidney disease progression in patients with CKD. METHODS:From the Cardiovascular and Metabolic Disease Etiology Research Center-HIgh Risk study (2013-2018), a total of 470 patients with CKD were analyzed. Ambulatory BP variability was assessed using average real variability (ARV). Primary outcome was composite of nonfatal myocardial infarction, nonfatal stroke, and all-cause mortality. The secondary outcome was rapid kidney function decline [estimated glomerular filtration rate (eGFR), >3 ml/min per 1.73m per year]. RESULTS:During a median follow-up of 51.8 (40.5-56.2) months, the incidences of all-cause death and composite outcomes were higher in the high SBP-ARV group than in the low SBP-ARV group. The Kaplan-Meier analysis showed that a high SBP-ARV, but not a high DBP-ARV and heart rate-ARV, was associated with higher composite outcome risks. In multivariable Cox analysis, a high SBP-ARV correlated with increased composite outcome risks (hazard ratio, 4.53; 95% confidence interval, 1.41-14.58). When subgroup analysis was performed (low vs. high 24-h SBP), this association was only significant in the high 24-h SBP group. The risk stratification for composite outcomes by adding SBP-ARV into the basic model and 24-h SBP, improved by 1.3%. Furthermore, the mean eGFR decline rate was faster, and the rapid eGFR decline risk was 1.68-fold higher in the high SBP-ARV group. CONCLUSION:Greater ambulatory SBP variabilities were associated with increased risks for nonfatal cardiovascular diseases, all-cause mortality, and rapid kidney function decline in patients with CKD.
10.1097/HJH.0000000000002477
Visit-to-visit blood pressure variability and risk of chronic kidney disease: A systematic review and meta-analyses.
Li Huihui,Xue Jing,Dai Wenjie,Chen Yusa,Zhou Qiaoling,Chen Wenhang
PloS one
OBJECTIVE:Previous studies have shown that visit-to-visit blood pressure variability (BPV) is associated with chronic kidney disease (CKD). However, the results have not been consistent among studies. This systematic review and meta-analysis was conducted to comprehensively assess the association between visit-to-visit BPV and the risk of CKD. METHODS:Medline, Embase, and the Cochrane Library were searched from the date of inception through 1 August 2019 using the terms "blood pressure variability," "chronic kidney disease," "nephropathy," and other comparable terms. The primary outcome was the development of CKD. Two reviewers extracted the data independently. Meta-analysis was performed using a random effects model. RESULTS:Fourteen studies were included in the systematic review and meta-analysis. The risk of CKD was significantly greater in patients with high baseline systolic blood pressure variability (SBPV) than in patients with low baseline SBPV: the standard deviation (SD) showed relative risk (RR) of 1.69 and 95% CI of 1.38-2.08, the coefficient of variation (CV) showed RR of 1.23 and 95% CI of 1.12-1.36, and variance independent of mean (VIM) showed RR of 1.40 and 95% CI of 1.15-1.71. RRs for each unit increase in visit-to-visit SBPV and risk of CKD were 1.05 (95% CI: 1.03-1.07) for SD, 1.06 (95% CI: 1.03-1.09) for CV, and 1.1 (95% CI: 0.96-1.25) for VIM. Diastolic BPV was similarly predictive of CKD based on SD and CV. CONCLUSIONS:Increased visit-to-visit BPV might be an independent risk factor for CKD. However, significant heterogeneity was present; thus, future prospective studies are needed to confirm our findings. Our results indicate that treatment of hypertension should control blood pressure levels and prevent abnormal fluctuations in blood pressure to reduce the risk of CKD.
10.1371/journal.pone.0233233
Long-term blood pressure variability and development of chronic kidney disease in type 2 diabetes.
Journal of hypertension
OBJECTIVE:Long-term visit-to-visit SBP variability (VVV) has been shown to predict cerebro-cardiovascular events and end-stage renal disease in chronic kidney disease (CKD) patients. Whether SBP VVV is also a predictor of CKD development in diabetes is currently uncertain. We assessed the role of SBP VVV on the development of CKD in patients with type 2 diabetes (T2D) and hypertension in real life. METHODS:Clinical records from 30 851 patients with T2D and hypertension, with normal estimated glomerular filtration rate (eGFR) and regular visits during a 4-year follow-up were analyzed. SBP variability was measured by three metrics: coefficient of variation; SD of the mean SBP and average absolute difference of successive values in each individual. CKD was defined as eGFR less than 60 and/or a reduction in eGFR at least 30% from baseline. RESULTS:Over the 4-year follow-up, 9.7% developed eGFR less than 60 and 4.5% an eGFR reduction at least 30% from baseline. Several clinical characteristics (older age, male sex, SBP, DBP, albuminuria, glycated hemoglobin, insulin treatment) were related to intraindividual SBP variability. Patients with VVV in the upper quintile showed an increased risk of developing both components of CKD [adjusted odds ratio (OR) 1.21, P < 0.001 and 1.32, P < 0.001, respectively]. The multivariable adjusted ORs of SBP coefficient of variation quintiles 2-5 for the incidence of CKD were incrementally higher (OR 1.04, P = 0.601, OR 1.05, P = 0.520, OR 1.21, P < 0.017 and OR 1.42, P < 0.001 as compared with the first quintile). CONCLUSION:Increased long-term BP variability predicts CKD in patients with T2D and hypertension.
10.1097/HJH.0000000000001950
Effect of blood pressure trajectory and variability on new-onset chronic kidney disease in patients with type 2 diabetes.
Hypertension research : official journal of the Japanese Society of Hypertension
This study aimed to evaluate the effects of BP trajectory and variability on chronic kidney disease (CKD) incidence in patients with type 2 diabetes. This retrospective longitudinal study included 4,560 participants with type 2 diabetes, aged ≥30 years, free of CKD, with ≥3 years of follow-up, and who attended the Diabetes Care Management Program in 2001-2013. The follow-up period ended in 2016. The adverse outcome was a new-onset CKD event, which was determined using eGFR and albuminuria. Cox proportional hazards models were used to assess the associations. At the end of the follow-up, 1255 participants had developed CKD, with a mean follow-up of 4.3 ± 3.2 years. Three trajectory subgroups of BP, i.e., Cluster 1: "moderate-stable" for SBP and "moderate-downward" for DBP, Cluster 2: "low-upward-downward" for both SBP and DBP, and Cluster 3: "high-downward-upward" for both SBP and DBP, were generated. The BP variability was grouped into three classes on the basis of tertiles. For the BP trajectory, patients in Cluster 3 of DBP had a higher CKD risk than those in Cluster 1 (HR = 1.24, 95% CI = 1.03-1.50). For the BP variability, patients in Tertile 3 had a significantly higher CKD risk than those in Tertile 1 (SBP: 1.28, 1.11-1.47; DBP: 1.17, 1.02-1.34). Persons with type 2 diabetes who achieved a small reduction in DBP after participating in the education program but rebounded and those who had the highest variation in both SBP and DBP faced the highest increase in CKD risk.
10.1038/s41440-022-00882-8
Augmented resting beat-to-beat blood pressure variability in patients with chronic kidney disease.
Clinical autonomic research : official journal of the Clinical Autonomic Research Society
PURPOSE:Our aim was to test the hypothesis that patients with chronic kidney disease (CKD) would exhibit augmented resting beat-to-beat blood pressure variability (BPV) that is associated with poor clinical outcomes independent of mean blood pressure (BP). In addition, since the arterial baroreflex plays a critical role in beat-to-beat BP regulation, we further hypothesized that an impaired baroreflex control would be associated with an augmented resting beat-to-beat BPV. METHODS:In 25 sedentary patients with CKD stages III-IV (62 ± 9 years) and 20 controls (57 ± 10 years), resting beat-to-beat BP (finger photoplethysmography) and heart rate (electrocardiography) were continuously measured for 10 min. We calculated the standard deviation (SD), average real variability (ARV) and other indices of BPV. The sequence technique was used to estimate spontaneous cardiac baroreflex sensitivity. RESULTS:Compared with controls (CON), the CKD group had significantly increased resting BPV. The ARV (2.2 ± 0.6 versus 1.6 ± 0.5 mmHg, P < 0.001; 1.6 ± 0.7 versus 1.3 ± 0.3 mmHg, P = 0.039; 1.4 ± 0.5 versus 1.0 ± 0.2 mmHg, P < 0.001) of systolic, diastolic and mean BP, respectively, was increased in CKD versus controls. Other traditional measures of variability showed similar results. The cardiac baroreflex sensitivity was lower in CKD compared with controls (CKD: 8.4 ± 4.5 ms/mmHg versus CON: 14.0 ± 8.2 ms/mmHg, P = 0.008). In addition, cardiac baroreflex sensitivity was negatively associated with BPV [systolic blood pressure (SBP) ARV; r = -0.44, P = 0.003]. CONCLUSION:In summary, our data demonstrate that patients with CKD have augmented beat-to-beat BPV and lower cardiac baroreflex sensitivity. BPV and cardiac baroreflex sensitivity were negatively correlated in this cohort. These findings may further our understanding about cardiovascular dysregulation observed in patients with CKD.
10.1007/s10286-023-00979-1
Day-to-Day Blood Pressure Variability and Risk of Incident Chronic Kidney Disease in a General Japanese Population.
Journal of the American Heart Association
Background Several longitudinal studies have reported that higher visit-to-visit blood pressure variability is associated with greater risk for developing chronic kidney disease. However, no population-based studies have investigated the association between day-to-day home blood pressure variability and incident chronic kidney disease. Methods and Results A total of 2342 Japanese community-dwelling residents aged ≥40 years without chronic kidney disease at baseline were followed up by annual health examinations for 10 years. Home blood pressure was measured 3 times every morning for 28 days. Day-to-day coefficients of variation of home systolic blood pressure levels were categorized into quintiles. Chronic kidney disease was defined as an estimated glomerular filtration rate <60 mL/min per 1.73 m or the presence of proteinuria. The hazard ratios for developing chronic kidney disease were estimated with a Cox proportional hazards model. During the follow-up period, 772 participants developed chronic kidney disease. Increased coefficients of variation of home systolic blood pressure were associated significantly with higher risk of chronic kidney disease after adjusting for confounders ( for trend <0.001): Individuals in the highest quintile of coefficients of variation had a 1.50-fold (95% CI, 1.17-1.94) greater risk of developing chronic kidney disease than those in the lowest quintile. The combination of higher coefficients of variation and higher mean value of home systolic blood pressure was associated with the multivariable-adjusted risk of developing chronic kidney disease. Conclusions These findings suggest that increased day-to-day blood pressure variability is a significant risk factor for developing chronic kidney disease in a general Japanese population.
10.1161/JAHA.122.027173
Effect of blood pressure index on clinical outcomes in patients with heart failure and chronic kidney disease.
ESC heart failure
AIMS:This study aimed to assess the effect of blood pressure (BP) index, in terms of level and variability, on the progression of cardiovascular and renal diseases in patients with both heart failure (HF) and chronic kidney disease (CKD). METHODS AND RESULTS:The study involved patients with HF and CKD from the database of the Chronic Renal Insufficiency Cohort (CRIC) study. The study endpoint includes the following: (i) primary endpoint, including cardiovascular disease (CVD) events, renal events, and all-cause death; (ii) CVD events; (iii) renal events; and (iv) all-cause death. Among 3939 participants in the CRIC study, a total of 382 patients were included. The duration of the follow-up was 6.3 ± 2.7 years, the age was 60.2 ± 8.9 years, and 57.6% were male. BP index included 20 indicators in relation to BP level and variability, 4 of which were analysed including baseline systolic BP (SBP), standard deviation of SBP, coefficient of variation of diastolic BP (DBP CV), and average real variability of pulse pressure. In the Cox regression analysis after adjustment, baseline SBP was significant for the risk of primary endpoint [hazard ratio (HR) 1.22, 95% confidence interval (CI) 1.03-1.44, P = 0.02] and renal events (HR 1.54, 95% CI 1.22-1.95, P < 0.001), and DBP CV was significant for the risk of primary endpoint (HR 1.03, 95% CI 1.01-1.06, P = 0.02) and CVD events (HR 1.04, 95% CI 1.02-1.07, P < 0.01). The result of the forest plot depicted that baseline SBP had a linear association with the risk of CVD and renal events (P = 0.04 and 0.001, respectively) and DBP CV with CVD events (P = 0.02). As the restricted cubic spline models displayed, DBP CV featured a J- or L-curved association with the primary endpoint, renal events, and all-cause death (P for nonlinearity = 0.01, <0.001, and 0.01, respectively). CONCLUSIONS:The baseline SBP and DBP CV may remain significant for clinical outcomes in patients with both HF and CKD. The increase in baseline SBP is associated with a higher risk of primary endpoint, CVD events, and renal events, and the increase in DBP CV with a higher risk of CVD events. Concerning nonlinear association, DBP CV features a J- or L-curved relationship with the primary endpoint, renal events, and all-cause death, with a higher risk at both low and high values. TRIAL REGISTRATION:https://www. CLINICALTRIALS:gov; unique identifier: NCT00304148.
10.1002/ehf2.14437
Association Between Systolic Blood Pressure Variability and Major Adverse Cardiovascular Events in Korean Patients With Chronic Kidney Disease: Findings From KNOW-CKD.
Journal of the American Heart Association
Background Whether visit-to-visit systolic blood pressure (SBP) variability can predict major adverse cardiovascular events (MACE) in patients with chronic kidney disease is unclear. Methods and Results We investigated the relationship between SDs of visit-to-visit SBP variability during the first year of enrollment and MACE among 1575 participants from KNOW-CKD (Korean Cohort Study for Outcome in Patients With Chronic Kidney Disease). Participants were categorized into 3 groups according to tertiles of visit-to-visit SBP variability (SD). The study end point was MACE, defined as a composite of nonfatal myocardial infarction, unstable angina, revascularization, nonfatal stroke, hospitalization for heart failure, or cardiac death. During 6748 patient-years of follow-up (median, 4.2 years), MACE occurred in 64 participants (4.1%). Compared with the lowest tertile of visit-to-visit SBP variability (SD), the hazard ratios (HRs) for the middle and the highest tertile were 1.64 (95% CI, 0.80-3.36) and 2.23 (95% CI, 1.12-4.44), respectively, in a multivariable cause-specific hazard model. In addition, the HR associated with each 5-mm Hg increase in visit-to-visit SBP variability (SD) was 1.21 (95% CI, 1.01-1.45). This association was consistent in sensitivity analyses with 2 additional definitions of SBP variability determined by the coefficient of variation and variation independent of the mean. The corresponding HRs for the middle and highest tertiles were 2.11 (95% CI, 1.03-4.35) and 2.28 (95% CI, 1.12-4.63), respectively, in the analysis with the coefficient of variation and 1.76 (95% CI, 0.87-3.57) and 2.04 (95% CI, 1.03-4.03), respectively, with the variation independent of the mean. Conclusions Higher visit-to-visit SBP variability is associated with an increased risk of MACE in patients with chronic kidney disease. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01630486.
10.1161/JAHA.122.025513
Ambulatory Blood Pressure Trajectories and Blood Pressure Variability in Diabetic and Non-Diabetic Chronic Kidney Disease.
Schoina Maria,Loutradis Charalampos,Minopoulou Ioanna,Theodorakopoulou Marieta,Pyrgidis Nikolaos,Tzanis George,Pella Eva,Papadopoulos Rafael,Papagianni Aikaterini,Sarafidis Pantelis A
American journal of nephrology
BACKGROUND:Diabetic kidney disease is the leading cause of end-stage renal disease worldwide. Whether diabetes mellitus (DM) is an additional factor leading to elevated blood pressure (BP) levels and BP variability (BPV) in patients with chronic kidney disease (CKD) is unknown. This study aimed to compare ambulatory BP levels, BP trends and BPV in diabetic and non-diabetic patients with CKD. METHODS:This study included 48 diabetic and 48 non-diabetic adult patients (>18 years) with CKD (estimated glomerular filtration rate [eGFR] <90 and ≥15 mL/min/1.73 m2), matched in a 1:1 ratio for age, sex and eGFR within each CKD stage (2, 3a, 3b and 4). All patients underwent 24-h ambulatory BP measurement with the Mobil-O-graph device. To evaluate the effect of DM and time on the trajectories of 24-h BP levels, we performed two-way mixed ANOVA analysis for repeated measurements using hourly means. BPV was calculated with validated formulas. RESULTS:In total, patients with DM had significantly higher 24-h systolic BP (SBP; 132.13 ± 10.71 vs. 124.16 ± 11.45; p = 0.001) and pulse pressure (PP; 57.1 ± 9.6 vs. 49.5 ± 10.9; p < 0.001), but similar 24-h diastolic BP (DBP; 75.00 ± 8.43 vs. 74.62 ± 6.86 mm Hg; p = 0.809) compared to patients without DM. A similar trend was evident across all CKD stages. The effect of DM on BP trajectories during the recording period was significant for SBP (F = 18.766, p < 0.001, partial η2 = 0.261) and marginally significant for DBP (F = 3.782, p = 0.057, partial η2 = 0.067). Twenty-four hour SBP SD, weighted SD (wSD) and average real variability (ARV; 10.94 ± 2.75 vs. 9.46 ± 2.10; p = 0.004), as well as 24 h DBP SD, wSD, coefficient of variation (CV) and ARV (8.23 ± 2.10 vs. 7.10 ± 1.33; p = 0.002) were significantly higher in diabetic compared to non-diabetic CKD patients. CONCLUSIONS:Ambulatory SBP and PP levels are higher and SBP-profile is different in patients with diabetic compared to those with non-diabetic CKD. Systolic and diastolic BPV are also higher in diabetics. These findings may signify a higher cardiovascular risk for patients with both DM and CKD compared to patients with CKD alone, through higher BP levels and BPV.
10.1159/000507416
Association of Blood Pressure Variability and Diuretics With Cardiovascular Events in Patients With Chronic Kidney Disease Stages 1-5.
Gregg L Parker,Hedayati S Susan,Yang Hui,Van Buren Peter N,Banerjee Subhash,Navaneethan Sankar D,Virani Salim S,Winkelmayer Wolfgang C,Alvarez Carlos A
Hypertension (Dallas, Tex. : 1979)
Visit-to-visit blood pressure variability (BPV) is associated with cardiovascular events in the general population. Data are scarce in chronic kidney disease. We hypothesized that BPV would be associated with cardiovascular outcomes, death, and end-stage kidney disease (ESKD) and that diuretics would modify these associations in patients with chronic kidney disease. We studied US Veterans with nondialysis chronic kidney disease stages 1-5 and hypertension on nondiuretic antihypertensive monotherapy. At the time of second antihypertensive agent prescription, we propensity-matched for exposure to a loop or thiazide diuretic versus any other antihypertensive. BPV was defined as the coefficient of variation of systolic blood pressure over 6 months after second agent prescription. Cox proportional hazards regression measured associations of BPV with a primary cardiovascular event composite (fatal or nonfatal myocardial infarction or ischemic stroke; heart failure hospitalization). Secondary outcomes included all-cause death, each primary outcome component, end-stage kidney disease, and cardiovascular death. There were 31 394 participants in each group. BPV was associated with composite cardiovascular events, hazard ratio (95% CI) at second, third, fourth, and fifth versus first quintile: 1.79 (1.53-2.11), 2.32 (1.99-2.71), 2.60 (2.24-3.02), and 3.12 (2.68-3.62). Diuretics attenuated associations between the fourth and fifth BPV quintiles with composite events (=0.03 and 0.04, respectively). BPV was associated with all secondary outcomes except end-stage kidney disease, with no diuretic interactions. BPV was associated with cardiovascular events and death but not end-stage kidney disease in patients with chronic kidney disease, with attenuated associations with cardiovascular events in the diuretic-treated group at high BPV quintiles. Future studies should investigate whether other antihypertensive classes modify these risks.
10.1161/HYPERTENSIONAHA.120.16117
Blood pressure variability and early neurological deterioration according to the chronic kidney disease risk categories in minor ischemic stroke patients.
PloS one
OBJECTIVE:Chronic kidney disease (CKD) increases blood pressure variability (BPV) and affects stroke outcomes. However, the effect of BPV on early neurological deterioration (END) may be different according to the renal function. METHODS:We enrolled ischemic stroke patients with a National Institutes of Health Stroke Scale of ≤5. END was defined as worsening of ≥1 point in motor power or ≥2 points in total score. BPV was calculated with BP measured during the first 5 days and presented as standard deviation (SD) and coefficient of variation (CoV). Renal function was classified using the Kidney Disease Improving Global Outcomes (KDIGO) classification of CKD. Variables were compared between those with (KDIGO classification: moderate- to very-high-risk) and without renal impairment (KDIGO classification: low-risk) and factors associated with END were investigated. RESULTS:Among the 290 patients (136 [46.9%] renal impairment), END was observed in 59 (20.3%) patients. BPV parameters and the risk of END increased as renal function was impaired. Renal function and systolic BP (SBP) mean, SD, CoV, and diastolic BP (DBP) mean, SD were independently associated with END. We found no association between BPV parameters and END in normal renal function patients; however, among impaired renal function patients, SBP SD (odds ratio [OR]: 1.20, 95% confidence interval [CI]: 1.09-1.32, P<0.001) and CoV (1.30 [1.12-1.50], P<0.001) were associated with END. CONCLUSIONS:The association between END and BPV parameters differs according to renal function in minor ischemic stroke; BPV was associated with END in patients with renal impairment, but less in those with normal renal function.
10.1371/journal.pone.0274180
Hypertension, Blood Pressure Variability, and Acute Kidney Injury in Hospitalized Children.
Journal of the American Heart Association
Background Although hypertensive blood pressure measurements are common in hospitalized children, the degree of inpatient hypertension and blood pressure variability (BPV) associated with end organ complications like acute kidney injury (AKI) is unknown. Methods and Results All analyses are based on a retrospective cohort of children aged 1 to 17 years with ≥2 creatinine measurements during admission from 2014 to 2018. We used time-updated Cox models to evaluate the association between BPV and hypertension with AKI. Time-varying BPV and hypertension were based on blood pressure in the preceding 72 hours. For the analysis of hypertension and AKI, we excluded patients on vasopressors to ensure comparison between hypertensive and normotensive patients. During 5425 pediatric encounters, 258 430 blood pressure measurements were recorded (median [interquartile range] 22 [11-47] readings per encounter). Among all measurements, 32.7% were ≥95th percentile and 18.9% were ≥99th percentile for age, sex, and height. AKI occurred in 389 (7.2%) encounters. We observed a U-shaped relationship between mean blood pressure and incident AKI. BPV was associated with AKI, with the largest effect sizes in the systolic and mean arterial pressure variability measures. Multiple hypertension thresholds were associated with AKI after controlling for confounders. In an additional multivariable model adjusted for BPV, the association between hypertension and AKI was attenuated but remained significant for hypertension defined as three stage 2 measurements in 1 day (hazard ratio, 1.43 [95% CI, 1.01-2.01]). Conclusions Hypertension and BPV are associated with AKI in hospitalized children. Future studies are needed to determine how pharmacologic and nonpharmacologic interventions modify AKI risk in pediatric inpatients with hypertension.
10.1161/JAHA.122.029059
Hypertension in Chronic Kidney Disease: An Update on Diagnosis and Management.
Southern medical journal
Hypertension (HTN) and chronic kidney disease (CKD) are pathophysiologic states that are intimately related, such that long-term HTN can lead to poor kidney function, and renal function decline can lead to worsening blood pressure (BP) control. HTN in CKD is caused by an interplay of factors, including salt and water retention, with extracellular volume expansion, sympathetic nervous system overactivity, renin-angiotensin-aldosterone system activation, and endothelial dysfunction. BP variability in the CKD population is significant, however, and thus requires close monitoring for appropriate management. With accumulating evidence, the diagnosis as well as management of HTN in CKD has been evolving in the last decade. In this comprehensive review based on current evidence and recommendations, we summarize the basics of pathophysiology, BP variability, diagnosis, and management of HTN in CKD with an emphasis on special populations with CKD.
10.14423/SMJ.0000000000001516
Hypertension and the kidneys.
British journal of hospital medicine (London, England : 2005)
Hypertension is a leading risk factor for cardiovascular disease and all-cause mortality globally. Hypertension and chronic kidney disease are closely intertwined conditions as hypertension can lead to deteriorating renal function and progressive chronic kidney disease can contribute to worsening hypertension. In the setting of chronic kidney disease, the pathophysiology of hypertension is complex and involves the interplay of many factors including a reduced number of functioning nephrons, sodium retention and volume expansion, upregulation of the sympathetic nervous system, hormonal factors such as upregulation of the renin-angiotensin-aldosterone system, and endothelial dysfunction. Poorly controlled hypertension can accelerate the progression to end-stage kidney disease. This review discusses the pathophysiological mechanisms that contribute to hypertension, including sympathetic nervous system activity, the renin-angiotensin-aldosterone system and the role of sodium. In the setting of chronic kidney disease, the relationship with hypertension and renovascular disease as a potential cause and target for therapeutic intervention is briefly reviewed. Finally, treatment options, targets and the long-term cardiovascular benefits of optimal blood pressure control are discussed.
10.12968/hmed.2021.0440