High-normal diastolic blood pressure is a risk for development of microalbuminuria in the general population: the Watari study

Home Blood Pressure-based Guidance Did not Increase Anti-albuminuric Effects on Diagnostic Provision of Microalbuminuria in School Workers: A Miyagi Karoshi Prevention Study

Objective We examined whether home blood pressure (BP)-based behavioural guidance had an additional anti-albuminuric effect on school workers with the simple diagnostic provision of microalbuminuria. Methods Of 169 school staff diagnosed with microalbuminuria (30-299.9 mg/gCr) in the annual 2019 health check-up, 91 agreed to receive home-BP-based guidance. Guidance comprised, for subjects with ≥ 135/85 mmHg, 5 days mean of home BP measurements, or encouraging medical consultation and lifestyle guidance; lifestyle guidance for subjects with BP 125-134/80-84 mmHg; and adequate lifestyle guidance for subjects BP<125/80 mmHg, if necessary. The main outcome was a change in the frequency of microalbuminuria the following year. Subjects with menstruation were excluded from analysis. Finally, there were 48 and 43 participants in guided and the non-guided groups, respectively. Results The guided and non-guided groups demonstrated similar baseline clinical data. Their prescription rates for hypertension (39.6 vs. 41.9 %) and diabetes (18.8 vs. 30.2 %) were similar. One year later, microalbuminuria was present in 31.2% and 30.2% of the guided and non-guided groups (n.s.), respectively, suggesting a ~70% risk reduction of microalbuminuria in both groups. Sensitivity analysis, excluding patients treated for hypertension or diabetes at baseline, demonstrated essentially similar results. In conclusion, the risk reduction of microalbuminuria was nearly 70% for both the home-BP-based guidance and non-guidance groups. Conclusion These data suggest that home BP-based guidance did not increase anti-albuminuric effects on simple diagnostic provision of microalbuminuria in school workers.

Addition of Metabolic Syndrome to Albuminuria Provides a New Risk Stratification Model for Diabetic Kidney Disease Progression in Elderly Patients

Elderly patients with type 2 diabetes (T2DM) are more prone to developing diabetic kidney disease (DKD). Patients with DKD can develop albuminuria, and some studies have suggested an association between metabolic syndrome and albuminuria. The prevalence of both metabolic syndrome and albuminuria increases with age. We evaluated the association of these risk factors with worsening renal function and albuminuria progression in 460 T2DM patients with a mean age of 72 years. During the 5-year follow-up period, progression of albuminuria and worsening of renal function were observed in 97 (21.2%) and 23 (5.1%) patients, respectively. After adjusting for confounding factors, the group with metabolic syndrome had a higher multivariable-adjusted hazard ratio (HR) for worsening renal function (P = 0.038) and albuminuria progression (P = 0.039) than the group without metabolic syndrome. When patients were divided into four groups according to the presence of metabolic syndrome and/or albuminuria, the HR gradually increased. The group with both albuminuria and metabolic syndrome exhibited the highest cumulative incidence of worsening renal function (P = 0.003). When we redefined metabolic syndrome to exclude the blood pressure (BP) component, similar results were obtained. We concluded that the presence of metabolic syndrome independently predicts the progression of renal disease in elderly patients with T2DM. The use of both metabolic syndrome and albuminuria provides a better risk stratification model for DKD progression than albuminuria alone.

Bidirectional and Temporal Association Between Hypertension and Microalbuminuria: A Longitudinal Study in Chinese Adults

Background Although hypertension and microalbuminuria are closely interrelated, the magnitude and temporal sequence of the bidirectional association between hypertension and microalbuminuria are largely unknown. We aimed to delineate the bidirectional and temporal relationship between hypertension and microalbuminuria. Methods and Results Leveraging a longitudinal cohort of Chinese adults who had blood pressure and urinary albumin measured twice 4 years apart, we examined the temporal association between hypertension and microalbuminuria by bidirectional and cross-lagged panel analysis. All participants were free of cardiovascular disease and chronic kidney disease at baseline. Bidirectional association analysis found that baseline microalbuminuria predicted the risk of incident hypertension (odds ratio=1.75, P=0.028), and baseline blood pressure also significantly predicted the risk of microalbuminuria (odds ratios=1.27 and 1.21 for a per-SD increase in systolic and diastolic blood pressure, respectively; all P<0.05). Cross-lagged panel analysis demonstrated a bottom-line significant relationship of baseline systolic blood pressure to follow-up urinary albumin ( P=0.079), which is significantly weaker than the other direction of the relationship of baseline urinary albumin to follow-up blood pressures (all P<0.001). Conclusions These findings indicate a significant bidirectional association between microalbuminuria and hypertension in Chinese adults. Elevated urinary albumin excretion is more likely to precede hypertension. The causality between microalbuminuria and hypertension needs further investigation.

Association of Blood Pressure Trajectories in Early Life with Subclinical Renal Damage in Middle Age

BACKGROUND

Although high BP is one of the most important factors affecting renal function, whether longitudinal BP trajectories in early life course are associated with renal function damage in later life is unclear.

METHODS

To investigate the correlation between BP trajectories from childhood to adulthood and renal function in middle age, we used group-based trajectory models to identify BP trajectories in 2430 individuals (aged 6-15 years old at baseline) participating in the ongoing Hanzhong Adolescent Hypertension Cohort. We tested the association between these trajectories and subclinical renal damage in middle age, adjusting for several covariates.

RESULTS

We identified four distinct systolic BP trajectories among 2430 subjects: low stable, moderate stable, high stable, and moderate increasing on the basis of systolic BP levels at baseline and during the 30-year follow-up period. The urinary albumin-to-creatinine ratio (uACR) was higher in moderate stable, high stable, and moderate increasing groups compared with the low stable group. A total of 228 individuals had subclinical renal disease by 2017. Compared with the low stable trajectory group, the other groups had increasingly greater odds of experiencing subclinical renal disease in middle age. These associations were not altered after adjustment for other covariates, except for in the moderate stable group. Analyzed results were similar for the mean arterial pressure and diastolic BP trajectory groups.

CONCLUSIONS

Higher BP trajectories were correlated with higher of uACR levels and risk of subclinical renal disease in middle age. Identifying long-term BP trajectories from early age may assist in predicting individuals' renal function in later life.

Effect of Long-Term Systolic Blood Pressure Trajectory on Kidney Damage in the Diabetic Population: A Prospective Study in a Community-Based Chinese Cohort

Background:

Previous studies have shown that hypertension is an important factor contributing to the occurrence and progression of diabetic kidney damage. However, the relationship between the patterns of blood pressure (BP) trajectory and kidney damage in the diabetic population remains unclear. This prospective study investigated the effect of long-term systolic BP (SBP) trajectory on kidney damage in the diabetic population based on an 8-year follow-up community-based cohort.

Methods:

This study included 4556 diabetic participants among 101,510 participants. BP, estimated glomerular filtration rate (eGFR), and urinary protein were measured every 2 years from 2006 to 2014. SBP trajectory was identified by the censored normal modeling. Five discrete SBP trajectories were identified according to SBP range and the changing pattern over time. Kidney damage was evaluated through eGFR and urinary protein value. A multivariate logistic regression model was used to analyze the influence of different SBP trajectory groups on kidney damage.

Results:

We identified five discrete SBP trajectories: low-stable group (n = 864), moderate-stable group (n = 1980), moderate increasing group (n = 609), elevated decreasing group, (n = 679), and elevated stable group (n = 424). The detection rate of kidney damage in the low-stable group (SBP: 118–124 mmHg) was the lowest among the five groups. The detection rate of each kidney damage index was higher in the elevated stable group (SBP: 159–172 mmHg) compared with the low-stable group. For details, the gap was 4.14 (11.6% vs. 2.8%) in eGFR <60 ml·min⁻¹·1.73 m⁻² and 3.66 (17.2% vs. 4.7%), 3.38 (25.0% vs. 7.4%), and 1.8 (10.6% vs. 5.9%) times in positive urinary protein, eGFR <60 ml·min⁻¹·1.73 m⁻² and/or positive urinary protein, and eGFR decline ≥30%, respectively (P < 0.01).

Conclusion:

An elevated stable SBP trajectory is an independent risk factor for kidney damage in the diabetic population.

Correlation between the trajectory of systolic blood pressure and new renal damage in a nonhypertensive population

OBJECTIVE

This study aims to investigate the correlation between the trajectory of systolic blood pressure (SBP) and new renal damage in a nonhypertensive population.

PATIENTS AND METHODS

This prospective cohort study included a total of 14 382 nonhypertensive individuals, employees of Kailuan Group of Companies, who took part in five healthy examinations in 2006-2007, 2008-2009, 2010-2011, 2012-2013, and 2014-2015, and had complete data. These individuals were divided into four groups according to the different trajectories of SBP: low-low, low-stable, middle-high, and high-high groups. The correlation between the trajectory of SBP and new renal damage in a nonhypertensive population was analyzed using a multivariate Cox's proportional hazard regression model.

RESULTS

(a) A total of 14 382 individuals had complete data and the average age of these individuals was 44.6±10.8 years. Among these, 10 888 (75.7%) individuals were men and 3494 (24.3%) individuals were women. (b) These individuals were divided into four groups according to different trajectories of blood pressure: low-low group, accounting for 13.15% (blood pressure was <106 mmHg); low-stable group, accounting for 53.91% (blood pressure was between 115 and 116 mmHg); middle-high group, accounting for 28.77% (blood pressure was between 125 and 131 mmHg); and high-high group, accounting for 4.6% (blood pressure was between 126 and 151 mmHg). (c) With the increase in the trajectory of SBP, the detection rate of renal damage increased gradually. From the low-low group to the high-high group, the detection rates of estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m were 2.3, 2.4, 3.6, and 4.3%, respectively; the positive rates of urinary protein were 1.7, 2.9, 3.8, and 5.5%, respectively; and the detection rates of eGFR less than 60 ml/min/1.73 m or positive urinary protein were 4, 5.2, 7.3, and 9.3%, respectively (P<0.05). (d) After adjustment for other confounding factors, multivariate Cox's proportional hazard regression analysis showed that compared with the low-low group, the risk of eGFR less than 60 ml/min/1.73 m increased by nearly 1.5 times in the high-high group and in the low-stable, middle-high, and high-high groups, the risks of positive urinary protein, eGFR less than 60 ml/min/1.73 m, or positive urinary protein increased by 1.48-2.34 and 1.20-1.70 times, respectively.

CONCLUSION

In a nonhypertensive population, the high trajectory of SBP is a risk factor for kidney damage.

Relationship between subtle urinary albumin excretion and risk of incident hypertension: modification by glomerular filtration rate

It has been reported that an increase in urinary albumin excretion (UAE) within the normal range could be a risk factor for incident hypertension. However, it remains unclear how the subtle increases in UAE and renal function interact in the development of hypertension. We examined the modification of UAE as a risk factor for incident hypertension by glomerular filtration rate (GFR) in the Japanese population. We prospectively followed 1281 normotensive individuals from Watari town (34.3% men; mean age, 58.0±12.3 years old) whose UAE was <30 mg g⁻¹· Cr. Hypertension was diagnosed as a systolic blood pressure (BP)⩾140 mm Hg and/or a diastolic BP⩾90 mm Hg, or antihypertensive medication use. The relationship between sex-specific quartiles of UAE and incident hypertension was examined with Cox proportional hazard analysis. During a mean follow-up of 3.7 years, 315 individuals developed hypertension. Multivariate Cox proportional hazard analysis revealed that a subtle increase in UAE was a risk factor for incident hypertension, but there was a significant interaction between UAE and estimated GFR (eGFR) (P=0.018). The risk of incident hypertension dose dependently increased in the highest eGFR quartile (⩾90 ml min⁻¹ per 1.73 m²). Decline in renal function alone increased the risk of incident hypertension but the increased risk with a subtle increase in UAE became smaller and less clear in the lower eGFR quartiles. The present data suggest that UAE as a risk factor for incident hypertension is largely dependent on eGFR levels.

Gender Differences in Lifestyle Factors Associated with Metabolic Syndrome and Preliminary Metabolic Syndrome in the General Population: The Watari Study

Objective In Japan, metabolic syndrome (MetS) and preliminary metabolic syndrome (preMetS) are more prevalent in men; however, it remains unclear whether the relationship between these metabolic disorders and lifestyle factors is similar between genders. Methods We examined waist circumference, blood pressure, fasting blood, and various lifestyle factors in 3,166 individuals aged from 30-79 years of age from the Japanese general population. MetS was diagnosed on the basis of central obesity - assessed by waist circumference - plus two or more of the following cardio-metabolic risks according to Japanese criteria: high blood pressure, hyperglycemia, and lipid abnormality. Central obesity plus one of the risks was defined as preMetS. Results Men had a significantly higher prevalence of MetS (23.3% vs. 8.7%, p<0.001) and preMetS (21.2% vs. 10.2%, p<0.001) than women. An age-adjusted logistic regression analysis revealed that heavy drinkers were associated with an increased probability of MetS (odds ratio, 1.91: 95% confidence interval, 1.29-2.83) and preMetS (1.69: 1.11-2.58); fast eaters were also related to preMetS (1.83: 1.33-2.55) and MetS (1.55: 1.12-2.15) in men. Lacking regular exercise was significantly associated with preMetS (1.38: 1.03-1.85), but not MetS. In women, preMetS was significantly associated with fast eaters and lacking regular exercise (1.44: 1.01-2.07 and 1.41: 1.02-1.96, respectively); a stepwise increase in each odds ratio (2.02: 1.40-2.91 and 1.47: 1.03-2.09, respectively) was also observed for MetS. Conclusion The relationships between lifestyle factors and MetS or preMetS differed between men and women, which suggests the need for gender-specific lifestyle modification to effectively prevent MetS.

Microalbuminuria in Obese Young and Middle Aged Population: A Potential Marker of Cardiovascular Risk

Microalbuminuria is an established cardiovascular risk indicator in diabetes, hypertension and the general population. There is lack of information on MAU in healthy obese Indian adults and an ongoing debate whether obese adults deserve targeted identification and clinical intervention for MAU and prediabetes. We aimed to screen the healthy obese, young (group I) and middle aged (group II) adults for prevalence of MAU and prediabetes and study its association with Framingham risk score. The study included 50 healthy obese young (20-30 years) and middle aged adults (31-50 years), attending the outpatient clinic of Dept. of Medicine for a duration of 2 months (July-August). The patients were screened for fasting blood sugar, lipid profile and MAU. Of the total patients 28 % had MAU, 32.14 % of which had prediabetes and 33.33 % had diabetes whereas 10 % were normoglycemic. The group I patients had 50 % cases of MAU and group II had 25 % patients with MAU. Group II 63.63 % pre-diabetics. The values of MAU obtained were correlated with age, gender, body mass index, systolic and diastolic blood pressure, FBS, waist to hip ratio using Pearson's Coefficient (p < 0.05). The 10 year CVD risk calculated using FRS in subjects with MAU was higher as compared to those without MAU. Thus we conclude that Indian, young and middle aged obese adults to be at a risk of prediabetes, MAU and CV risk warranting their routine screening for better clinical outcomes.

Moderately increased albuminuria is an independent risk factor of cardiovascular events in the general Japanese population under 75 years of age: the Watari study

Background

Moderately increased albuminuria (formerly called microalbuminuria) is widely recognized as a predictor of cardiovascular disease. However, it is not clear whether this observation is applicable to the Asian population, as studies leading to this conclusion were conducted on Western populations. The aim of this study was to examine the hypothesis if moderately increased albuminuria could be an independent predictor of cardiovascular mortality and morbidity in the Japanese population.

Methods and Results

The study population consisted of 3093 inhabitants of Watari, Miyagi Prefecture, who participated in an annual health check-up in 2009. We examined anthropometry, sitting blood pressure, fasting blood sample, and urine albumin-to-creatinine ratio (UACR). After baseline assessment, subjects were followed prospectively for up to 60 months. The incidence of major cardiovascular events (stroke, myocardial infarction, revascularization, and cardiovascular death) was determined based on death certificate records or medical claims sent to the National Health Insurance of Japan. Follow-up was discontinued for those who reached 75 years of age because they were moved to a different medical insurance system. We observed 57 cardiovascular events during a mean follow-up period of 47.8 months. The cumulative incidence rate for major cardiovascular events was significantly higher in patients with moderately increased albuminuria (UACR 30–299 mg/gCr) than in those with normoalbuminuria (UACR <30 mg/gCr) (6.4% vs. 2.2%, p = 0.0002 by log-rank test). Multivariate Cox proportional hazards analyses have revealed that moderately increased albuminuria is an independent predictor of cardiovascular events (HR 2.386, 95% CI: 1.120–4.390).

Conclusions

Moderately increased albuminuria is an independent predictor of cardiovascular events in the general Japanese population under 75 years of age.

Blood pressure among public employees after the Great East Japan Earthquake: the Watari study

BACKGROUND

Increases in blood pressure were reported in overworked public workers following the Mid-Niigata earthquake. This study aimed to compare blood pressure changes between public employees and the general population after the Great East Japan Earthquake of March 2011.

METHODS

We analyzed 1,776 individuals from the general population and 240 public employees of the town of Watari who received medical check-ups in 2010 and from July 2011 through November 2011. Anthropometric parameters and sitting blood pressure were compared, and fasting blood samples were taken from all participants. In post-disaster measurements, the degrees of insomnia, depression, fatigue, and life disruption due to the disaster were assessed using a questionnaire. Information on the working hours of public employees was obtained from authorized sources.

RESULTS

After age-sex adjustments, the public employees showed greater increases in systolic (11.3 vs. -1.9mm Hg, P < 0.001) and diastolic (7.8 vs. 1.1mm Hg, P < 0.001) blood pressure than the general population when compared with measurements taken during the previous year. In contrast, the degrees of fatigue, depression, and life disruption were equivalent in the 2 groups. The average monthly overtime hours worked by public employees in March 2011 was 10-fold higher compared with the previous March.

CONCLUSION

Public employees showed greater and more prolonged increases in blood pressure than the general population after the Great East Japan earthquake. Thus blood pressure should be monitored after a great earthquake among public employees, and treatment should be considered if necessary.