Long-Term Blood Pressure Variability, New-Onset Diabetes Mellitus, and New-Onset Chronic Kidney Disease in the Japanese General Population

Effects of a High-Protein Diet on Kidney Injury under Conditions of Non-CKD or CKD in Mice

Considering the prevalence of obesity and global aging, the consumption of a high-protein diet (HPD) may be advantageous. However, an HPD aggravates kidney dysfunction in patients with chronic kidney disease (CKD). Moreover, the effects of an HPD on kidney function in healthy individuals are controversial. In this study, we employed a remnant kidney mouse model as a CKD model and aimed to evaluate the effects of an HPD on kidney injury under conditions of non-CKD and CKD. Mice were divided into four groups: a sham surgery (sham) + normal diet (ND) group, a sham + HPD group, a 5/6 nephrectomy (Nx) + ND group and a 5/6 Nx + HPD group. Blood pressure, kidney function and kidney tissue injury were compared after 12 weeks of diet loading among the four groups. The 5/6 Nx groups displayed blood pressure elevation, kidney function decline, glomerular injury and tubular injury compared with the sham groups. Furthermore, an HPD exacerbated glomerular injury only in the 5/6 Nx group; however, an HPD did not cause kidney injury in the sham group. Clinical application of these results suggests that patients with CKD should follow a protein-restricted diet to prevent the exacerbation of kidney injury, while healthy individuals can maintain an HPD without worrying about the adverse effects.

Long-Term Visit-To-Visit Blood Pressure Variability and Risk of Diabetes Mellitus in Chinese Population: A Retrospective Population-Based Study

Objectives: To examine the association between visit-to-visit blood pressure variability (BPV) and incident diabetes mellitus (DM) risk in a Chinese population. Methods: Data comes from China Health and Nutrition Survey (n = 15,084). BPV was estimated as the average real variability (ARV) using at least three BP measurements from the year preceding the event and was divided into quartiles. Participants were also categorized into 9 groups on the basis of combinations of systolic BPV (SBPV) and diastolic BPV (DBPV) tertiles. Cox proportional hazards regression models were used. Results: During a median follow-up of 16.8 years, 1,030 (6.8%) participants developed diabetes (incidence rate: 4.65/1,000 person-years). The HRs (95% CIs) for the highest quartile (vs. the lowest quartile) of SBPV and DBPV were 1.60 (1.30-1.97) and 1.37 (1.13-1.67), respectively. Participants with both highest SBPV and DBPV tertile had an ≈89% higher risk of DM (HR, 1.89; 95% CI, 1.47-2.42) compared with those in the both SBPV and DBPV tertile 1 group. Conclusion: Higher SBP ARV and DBP ARV were independently associated with increased risk of incident DM, which was augmented when both presented together.

Visit-to-visit SBP variability and risk of atrial fibrillation in middle-aged and older populations

OBJECTIVE

We sought to examine the relationship between visit-to-visit variability of SBP and incident atrial fibrillation in middle-aged and older population.

METHODS

This prospective cohort study included 26 999 participants aged 50 years or older at study entry. Visit-to-visit variability of SBP was defined as the average real variability (ARV) of three values of SBP from the examinations of 2006, 2008, and 2010. We categorized participants into four groups according to the quartiles of ARV. Incident atrial fibrillation cases were identified via ECG during biennial resurveys, and reviewing medical insurance record and discharge registers. We used Cox regression models to evaluate the hazard ratios and 95% confidence intervals (CI) for incident atrial fibrillation.

RESULTS

After an average follow-up of 9.24 years, a total of 420 atrial fibrillation cases were identified. The incidence of atrial fibrillation from the lowest to the highest quartiles of SBP variability were 1.23, 1.53, 1.81 and 2.19 per 1000 person-years, respectively. After adjusting for potential confounders, including mean blood pressure, we found a graded association between SBP variability and risk of atrial fibrillation. Participants in the third quartile and the highest quartile were associated with 35 and 53% higher risk of developing atrial fibrillation, respectively, compared with participants in the lowest quartile [hazard ratio (95% CI), 1.35 (1.01-1.82) and 1.53 (1.15-2.04)]. The results persisted across sensitivity analyses.

CONCLUSION

Increased visit-to-visit variability of SBP is a strong predictor of incident atrial fibrillation in middle-aged and older population. Evaluation of long-term SBP variability could help to identify individuals at higher risk of atrial fibrillation.

Day-to-Day Blood Pressure Variability and Risk of Incident Chronic Kidney Disease in a General Japanese Population

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 m² 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 (P 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.

Association between visit-to-visit blood pressure variability and adverse events in coronary artery disease patients after coronary intervention

Blood pressure variability (BPV) is independently associated with higher cardiovascular risks. However, whether BPV is associated with poor outcomes for coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI) remained undetermined. We aimed to investigate the relationship between BPV and the outcomes of CAD patients undergoing PCI. Two thousand seven hundred and sixty-two CAD patients (1938 males, mean age 69.6 ± 12.9) who received PCI at Taipei Veterans General Hospital from 2006 to 2015 with multiple blood pressure measurements before and after the index PCI were enrolled. We calculated the standard deviation of systolic blood pressure, diastolic blood pressure, and pulse pressure as parameters of BPV. The primary endpoint was the composite of major adverse cardiovascular events [MACE comprising of cardiovascular death, nonfatal myocardial infarction (MI), and non-fatal stroke] and heart failure hospitalization (HHF). The key secondary endpoint was MACE. Both pre-PCI and post-PCI BPV were associated with CV events even after adjusting for co-morbidities and mean blood pressure. In Cox analysis, for every 1 mmHg increase in systolic BPV, the hazard ratio for the MACE + HHF, MACE, HHF, and cardiovascular death was 1.04 (95%CI: 1.03-1.05), 1.04 (95%CI: 1.02-1.05), 1.05 (95%CI: 1.04-1.06), and 1.06 (95%CI: 1.03-1.09), respectively. The association between BPV and cardiovascular risk is independent of blood pressure control status. The prognostic value of BPV was superior to mean blood pressure in both pre-PCI and post-PCI period. BPV is independently associated with cardiovascular events after PCI and has a better prognostic value than mean blood pressure suggesting the importance of maintaining stable blood pressure for CAD patients.

Variabilidade da Pressão Arterial em Única Visita e Risco Cardiovascular em Participantes do ELSA-Brasil

Fundamento

A variabilidade da pressão arterial (VPA) tem valor prognóstico para desfechos cardiovasculares fatais e não fatais.

Objetivos

Este estudo teve como objetivo avaliar a associação entre a VPA em uma única visita e o risco cardiovascular em participantes do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil).

Métodos

O presente estudo transversal foi conduzido com dados basais (2008-2010) de 14.357 participantes do ELSA-Brasil, sem história de doença cardiovascular. A VPA foi quantificada pelo coeficiente de variação de três medidas padronizadas da pressão arterial sistólica (PAS) realizadas com um oscilômetro. Medidas antropométricas e exames laboratoriais também foram realizados. O risco cardiovascular foi avaliado pelo estimador de risco de doença cardiovascular aterosclerótica (ASCVD), e se empregou a análise de regressão logística multivariada com nível de significância de 5%.

Resultados

Um risco cardiovascular significativamente maior foi determinado por uma VPA elevada para ambos os sexos. Uma prevalência significativamente maior de alto risco foi observada mais em homens que em mulheres em todos os quartis, com a maior diferença observada no quarto quartil de variabilidade (48,3% vs. 17,1%). Comparações entre quartis por sexo revelaram um risco significativamente mais alto para homens no terceiro (OR=1,20; IC95%: 1,02 - 1,40) e no quarto quartis OR=1,46; IC95%: 1,25 -1,71), e para mulheres no quarto quartil (OR=1,27; IC95%: 1,03 - 1,57).

Conclusão

Análises de dados basais de participantes do ELSA-Brasil revelaram que a variabilidade da pressão arterial se associou com risco cardiovascular aumentado, especialmente nos homens.

Long-term variability and change trend of systolic blood pressure and risk of type 2 diabetes mellitus in middle-aged Japanese individuals: findings of the Aichi Workers' Cohort Study

Studies have reported that short-term blood pressure (BP) variability (BPV) is associated with type 2 diabetes mellitus (T2DM) incidence, but the association with long-term BPV remains unclear. The present study investigated the associations of long-term BPV as well as the time trend of BP changes over time with the incidence of T2DM. This study followed a cohort of 3017 Japanese individuals (2446 male, 571 female) aged 36-65 years from 2007 through March 31, 2019. The root-mean-square error (RMSE) and the slope of systolic BP (SBP) change regressed on year were calculated individually using SBP values obtained from 2003 to baseline (2007). A multivariable Cox proportional hazard model was applied to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) for tertiles of SBP RMSE and continuous SBP slopes adjusted for age, sex, smoking status, regular exercise, sodium intake, family history of diabetes, sleep disorder, body mass index (BMI), SBP, and fasting blood glucose (FBG) at baseline, and BMI slope from 2003 to 2007. The highest RMSE tertile compared to the lowest was associated with a significantly higher incidence of T2DM after adjusting for covariates (HR: 1.79, 95% CI: 1.15, 2.78). The slope was also significantly associated with T2DM incidence until baseline SBP and FBG were adjusted (HR: 1.03, 95% CI: 0.99, 1.07). In conclusion, long-term SBP variability was significantly associated with an increased incidence of T2DM independent of baseline age, sex, BMI, SBP, FBG, lifestyle factors and BMI slope from 2003 until baseline.

Associations of Long-Term Visit-to-Visit Blood Pressure Variability With Subclinical Kidney Damage and Albuminuria in Adulthood: a 30-Year Prospective Cohort Study

BACKGROUND

Recent evidence indicates that long-term visit-to-visit blood pressure variability (BPV) may be associated with risk of cardiovascular disease. We, therefore, aimed to determine the potential associations of long-term BPV from childhood to middle age with subclinical kidney damage (SKD) and albuminuria in adulthood.

METHODS

Using data from the ongoing cohort of Hanzhong Adolescent Hypertension study, which recruited children and adolescents aged 6 to 18 years at baseline, we assessed BPV by SD and average real variability (ARV) for 30 years (6 visits). Presence of SKD was defined as estimated glomerular filtration rate between 30 and 60 mL/min per 1.73 m² or elevated urinary albumin-to creatinine ratio at least 30 mg/g. Albuminuria was defined as urinary albumin-to creatinine ratio ≥30 mg/g.

RESULTS

During 30 years of follow-up, of the 1771 participants, 204 SKD events occurred. After adjustment for demographic, clinical characteristics, and mean BP during 30 years, higher SD_SBP , ARV_SBP , SD_DBP , ARV_DBP , SD_MAP , ARV_MAP , and ARV_PP were significantly associated with higher risk of SKD. When we used cumulative exposure to BP from childhood to adulthood instead of mean BP as adjustment factors, results were similar. In addition, greater long-term BPV was also associated with the risk of albuminuria. Long-term BPV from childhood to middle age was associated with higher risk of SKD and albuminuria in adulthood, independent of mean BP or cumulative exposure to BP during follow-up.

CONCLUSIONS

Identifying long-term BPV from early age may assist in predicting kidney disease and cardiovascular disease in later life.

Triglyceride to High-Density Lipoprotein Cholesterol (TG/HDL-C) Ratio, a Simple but Effective Indicator in Predicting Type 2 Diabetes Mellitus in Older Adults

BACKGROUND

A simple and readily available biomarker can provide an effective approach for the surveillance of type 2 diabetes mellitus (T2DM) in the elderly. In this research, we aim to evaluate the role of triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio as an indicator for new-onset T2DM in an elderly Chinese population aged over 75 years.

METHODS

This longitudinal retrospective cohort study was conducted using a free database from a health check screening project in China. Participants with baseline TG and HDL measurements were enrolled, and the data of T2DM development were collected. The cumulative incident T2DM rates in different quintile groups of TG/HDL-C ratio (Q1 to Q5) were calculated and plotted. The independent effect of baseline TG/HDL-C ratio on T2DM risk during the follow-up period was tested by the Cox proportional hazard model. Subgroup analysis was also conducted to clarify the role of TG/HDL-C ratio in specific populations.

RESULTS

A total of 231 individuals developed T2DM among 2,571 subjects aged over 75 years during follow-up. Regardless of adjustment for potential confounding variables, elevated TG/HDL-C ratio independently indicated a higher risk of incident T2DM [hazard ratio (HR) = 1.29; 95% confidence interval (CI), 1.14-1.47; P < 0.01. As compared with the lowest quintile (Q1), elevated TG/HDL-C ratio quintiles (Q2 to Q5) were associated with larger HR estimates of incident T2DM [HR (95% CI), 1.35 (0.85-2.17), 1.31 (0.83-2.06), 1.85 (1.20-2.85), and 2.10 (1.38-3.20), respectively]. In addition, a non-linear correlation was found between TG/HDL-C ratio and the risk of T2DM, and the slope of the curve decreased after the cutoff point of 2.54. Subgroup analysis revealed a stronger positive correlation among male individuals and those with body mass index <24 kg/m².

CONCLUSIONS

Increased TG/HDL-C ratio indicates a greater risk of new-onset T2DM regardless of confounding variables. TG/HDL-C ratio is a simple but effective indicator in predicting T2DM in older adults. More future investigations are warranted to further promote the clinical application of TG/HDL-C ratio.

Application of machine learning techniques to understand ethnic differences and risk factors for incident chronic kidney disease in Asians

INTRODUCTION

Chronic kidney disease (CKD) is increasing in Asia, but there are sparse data on incident CKD among different ethnic groups. We aimed to describe the incidence and risk factors associated with CKD in the three major ethnic groups in Asia: Chinese, Malays and Indians.

RESEARCH DESIGN AND METHODS

Prospective cohort study of 5580 general population participants age 40-80 years (2234 Chinese, 1474 Malays and 1872 Indians) who completed both baseline and 6-year follow-up visits. Incident CKD was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² in those free of CKD at baseline.

RESULTS

The 6-year incidence of CKD was highest among Malays (10.0%), followed by Chinese (6.1%) and Indians (5.8%). Logistic regression showed that older age, diabetes, higher systolic blood pressure and lower eGFR were independently associated with incident CKD in all three ethnic groups, while hypertension and cardiovascular disease were independently associated with incident CKD only in Malays. The same factors were identified by machine learning approaches, gradient boosted machine and random forest to be the most important for incident CKD. Adjustment for clinical and socioeconomic factors reduced the excess incidence in Malays by 60% compared with Chinese but only 13% compared with Indians.

CONCLUSION

Incidence of CKD is high among the main Asian ethnic groups in Singapore, ranging between 6% and 10% over 6 years; differences were partially explained by clinical and socioeconomic factors.

Triglyceride to high-density lipoprotein cholesterol ratio variability and incident diabetes: A 7-year prospective study in a Chinese population

AIMS/INTRODUCTION

The correlation between triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio variability and incident diabetes has not been fully elucidated. We aimed to characterize the relationship between TG/HDL-C ratio variability and new-onset diabetes in Chinese adults.

MATERIALS AND METHODS

A total of 45,911 patients with three TG and HDL measurements between 2006 and 2011 were enrolled. Average real variability (ARV) were used to evaluate variability, and participants were grouped according to tertiles of TG/HDL-ARV.

RESULTS

There were 3,724 cases of incident diabetes mellitus during the observation period (6.24 ± 1.2 years). The 7-year cumulative incidences of diabetes mellitus in tertiles 1, 2 and 3 were 6.13%, 8.09% and 11.77%, respectively. New-onset diabetes increased with the tertiles of TG/HDL-ARV. This association was further confirmed after adjustment for mean TG/HDL-C ratio, TG/HDL-C ratio change slope, fasting plasma glucose variability (ARV) and other traditional risk factors for diabetes, the hazard ratio value for incident diabetes was 1.38 (1.25-1.50) for the highest tertile, and risk of diabetes increases by 4% with a one standard deviation increase in TG/HDL-C ratio variability. Restricted cubic splines showed a dose-response relationship between TG/HDL-C ratio variability and incident diabetes. Similar results were obtained in various subgroup and sensitivity analyses.

CONCLUSIONS

High TG/HDL-C variability was associated with a higher risk of diabetes in Chinese adults, independent of the direction of TG/HDL-C variability.

Long-term blood pressure variability, incidence of hypertension and changes in renal function in type 2 diabetes

OBJECTIVES

Long-term visit-to-visit SBP variability (VVV) predicts cerebro-cardiovascular and renal events in patients with hypertension. Whether VVV predicts hypertension and/or chronic kidney disease is currently unknown. We assessed the role of VVV on the development of hypertension and changes in renal function in patients with type 2 diabetes and normal blood pressure (NBP) in a real-life clinical setting.

METHODS

Clinical records from 8998 patients with type 2 diabetes, NBP, and normal estimated glomerular filtration rate (eGFR) were analyzed. VVV was measured by SD of the mean SBP recorded in at least four visits during 2 consecutive years before follow-up. Hypertension was defined as SBP at least 140 mmHg and DBP at least 90 mmHg or the presence of antihypertensive treatment. Renal function was defined as worsening of albuminuria status and/or a reduction in eGFR at least 30% from baseline.

RESULTS

After a mean follow-up time of 3.5 ± 2.8 years, 3795 patients developed hypertension (12.1 per 100 person-years). An increase of 5 mmHg VVV was associated with a 19% (P < 0.0001) and a 5% (P = 0.008) independent increased risk of developing hypertension and worsening of albuminuria, respectively. We found no association between VVV and eGFR decrease from baseline. Patients with VVV in the upper quartile (>12.8 mmHg) showed a 50% increased risk of developing hypertension (P < 0.0001) and an almost 20% increased risk of worsening albuminuria (P = 0.004) as compared with those in the lower one (<6.9 mmHg).

CONCLUSION

Increased VVV independently predicts incident hypertension and albuminuria worsening in type 2 diabetes and NBP.

Burden of chronic kidney disease and rapid decline in renal function among adults attending a hospital-based diabetes center in Northern Europe

Introduction

This study aimed to determine the prevalence of diabetic kidney disease (DKD) and rapid renal function decline and to identify indices associated with this decline among adults attending a diabetes center in Northern Europe.

Research design and methods

This is a retrospective cohort study of 4606 patients who attended a diabetes center in Ireland between June 2012 and December 2016. Definition/staging of chronic kidney disease used the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 classification based on data from the most recently attended appointment. Relevant longitudinal trends and variabilities were derived from serial records prior to index visit. Rapid renal function decline was defined based on per cent and absolute rates of estimated glomerular filtration rate (eGFR) change. Multiple linear regression was used to explore the relationships between explanatory variables and per cent eGFR change.

Results

42.0% (total), 23.4% (type 1 diabetes), 47.9% (type 2 diabetes) and 32.6% (other diabetes) had DKD. Rapid decline based on per cent change was more frequent in type 2 than in type 1 diabetes (32.8% vs 14.0%, p<0.001). Indices independently associated with rapid eGFR decline included older age, greater number of antihypertensives, higher log-normalized urine albumin to creatinine ratio (LNuACR), serum alkaline phosphatase, thyroid stimulating hormone, variability in systolic blood pressure and variability in LNuACR, lower glycated hemoglobin, high-density lipoprotein cholesterol and diastolic blood pressure, and lack of ACE inhibitor/angiotensin receptor blocker prescription.

Conclusions

DKD (using the KDIGO 2012 classification) and rapid eGFR decline were highly prevalent among adults attending a hospital-based diabetes clinic in a predominantly Caucasian Northern European country. The burden was greater for adults with type 2 diabetes. Expected as well as potentially novel clinical predictors were identified.

Predictive value of visit-to-visit blood pressure variability for cardiovascular events in patients with coronary artery disease with and without diabetes mellitus

Background

High blood pressure is a major risk factor for cardiovascular disease. Visit-to-visit blood pressure variability (BPV) has recently been shown to predict cardiovascular outcomes. We investigated the predictive value of BPV for major adverse cardiovascular events (MACE) among patients with coronary artery disease (CAD), with and without type 2 diabetes mellitus (T2DM).

Methods

Patients with stable CAD were enrolled and monitored for new MACE. Visit-to-visit BPV was defined as the coefficient of variation (CV) of systolic and diastolic BP across clinic visits. Multivariable logistic regression analysis was performed to evaluate the association of BPV with MACE. Area under the receiver operating characteristic curve (AUC) was used to assess its predictive ability.

Results

Among 1140 Chinese patients with stable CAD, 192 (17%) experienced a new MACE. In multivariable analyses, the risk of MACE was significantly associated with CV of systolic BP (odds ratio [OR] for highest versus lowest quartile, 3.30; 95% CI 1.97–5.54), and diastolic BP (OR for highest versus lowest quartile, 2.39; 95% CI 1.39–4.11), after adjustment for variables of the risk factor model (age, gender, T2DM, hypertension, antihypertensive agents, number of BP measurements) and mean BP. The risk factor model had an AUC of 0.70 for prediction of MACE. Adding systolic/diastolic CV into the risk factor model with mean BP significantly increased the AUC to 0.73/0.72 (P = 0.002/0.007). In subgroup analyses, higher CV of systolic BP remained significantly associated with an increased risk for MACE in patients with and without T2DM, whereas the association of CV of diastolic BP with MACE was observed only in those without T2DM.

Conclusions

Visit-to-visit variability of systolic BP and of diastolic BP was an independent predictor of new MACE and provided incremental prognostic value beyond mean BP and conventional risk factors in patients with stable CAD. The association of BPV in CAD patients without T2DM with subsequent risk for MACE was stronger than in those with T2DM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01280-z.

The Population-Attributable Fraction for Premature Mortality Due to Cardiovascular Disease Associated With Stage 1 and 2 Hypertension Among Japanese

BACKGROUND

Our aim was to assess how the population-attributable fraction (PAF) for premature mortality due to cardiovascular disease (CVD) associated with hypertension changes if blood pressure (BP) thresholds for hypertension were lowered from systolic/diastolic BP ≥140/90 mm Hg to ≥130/80 mm Hg, as defined using the 2017 American College of Cardiology/American Heart Association blood pressure guideline.

METHODS

Analyses were conducted using a database of participants who underwent a national health checkup examination started in 2008 in Japan (n = 510,238; mean age, 59.6 ± 8.1 years; 42% men). Each participant was categorized as having normal or elevated BP, or stage 1 or 2 hypertension according to the guideline. Data on premature mortality due to CVD occurring before age 70 years were available through March 2015.

RESULTS

Over a median follow-up of 3.4 years, 739 deaths from CVD occurred. After multivariable adjustment, hazard ratios for premature CVD mortality for elevated BP, stage 1 hypertension, and stage 2 hypertension vs. normal BP were 1.02 (95% confidence interval, 0.72, 1.44), 1.33 (1.02, 1.75), and 2.41 (1.90, 3.05), respectively. The PAF associated with stage 1 and 2 hypertension was 4.4% and 39.4%, respectively.

CONCLUSIONS

In the current nationwide study of Japanese adults, stage 1 and 2 hypertension were associated with an increased risk for premature CVD mortality. The PAF for premature CVD mortality associated with hypertension increased by 4.4% if BP thresholds for hypertension were lowered from systolic/diastolic BP ≥140/90 to ≥130/80 mm Hg.

Fast walking is a preventive factor against new-onset diabetes mellitus in a large cohort from a Japanese general population

Based on questionnaires from 197,825 non-diabetic participants in a large Japanese cohort, we determined impact of (1) habit of exercise, (2) habit of active physical activity (PA) and (3) walking pace on new-onset of type 2 diabetes mellitus. Unadjusted and multivariable-adjusted logistic regression models were used to determine the odds ratio of new-onset diabetes mellitus incidence in a 3-year follow-up. There were two major findings. First, habits of exercise and active PA were positively associated with incidence of diabetes mellitus. Second, fast walking, even after adjusting for multiple covariates, was associated with low incidence of diabetes mellitus. In the subgroup analysis, the association was also observed in participants aged ≥ 65 years, in men, and in those with a body mass index ≥ 25. Results suggest that fast walking is a simple and independent preventive factor for new-onset of diabetes mellitus in the health check-up and guidance system in Japan. Future studies may be warranted to verify whether interventions involving walking pace can reduce the onset of diabetes in a nation-wide scale.

Visit-to-visit variability in blood pressure and the development of chronic kidney disease in treated general hypertensive patients

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.

Impact of Metabolic Syndrome on the Mortality Rate among Participants in a Specific Health Check and Guidance Program in Japan

Objective In Japan, the Specific Health Check and Guidance (Tokutei-Kenshin) program was started in 2008 to decrease the social burden related to metabolic syndrome (MetS). However, so far this program has not been found to have any impact on the mortality rate. Methods The subjects consisted of individuals who participated in the Tokutei-Kenshin in seven districts between 2008 and 2015. Using a National database of death certificates, we identified those who might have died and then further confirmed such deaths with the collaboration of the regional National Health Insurance agency and public health nurses. The diagnosis of MetS was made according to the Japanese criteria. The causes of death were classified by ICD-10. Mortality risk was evaluated after adjusting for age, sex, smoking, alcohol intake and past medical history such as stroke, heart disease and kidney disease. Results Among the total of 664,926 subjects, we identified 8,051 fatal cases by the end of 2015. The crude death rate was 1.6% for those with MetS, 1.3% for those with preliminary metabolic syndrome, and 1.1% those without MetS. In MetS, the adjusted hazard ratio (95% confidence interval) was 1.08 (1.02-1.15) for all-cause and 1.39 (1.22-1.58) for cardiovascular disease mortality when the reference was for those without MetS. Conclusion The death rate was found to be significantly higher among the participants with MetS.

Association of Variability in Body Mass Index and Metabolic Health With Cardiometabolic Disease Risk

Background Metabolic syndrome is associated with high risk of cardiovascular disease, although risk may differ according to the specific conditions present and variability in those conditions. Methods and Results We defined obesity (body mass index [BMI] ≥30 kg/m²) and metabolic health (<2 nonobesity National Cholesterol Education Program Adult Treatment Panel III conditions) among 3632 Framingham Heart Study offspring cohort participants (mean age, 50.8 years; 53.8% women) who were followed up from 1987 to 2014. We defined participants whose variance independent of the mean for a metabolic syndrome-associated measure was in the top quintile as being "variable" for that measure. Variable metabolic health was defined as ≥2 variable nonobesity metabolic syndrome components. We investigated the interaction between obesity and metabolic health in their associations with cardiometabolic disease and cardiovascular disease using Cox proportional hazards regression. In addition, we estimated the associations of BMI variability and variable metabolic health with study outcomes within categories of obesity and metabolic health status, respectively. We observed 567 incident obesity (41 439 person-years), 771 incident metabolically unhealthy state (25 765 person-years), 272 incident diabetes mellitus (56 233 person-years), 503 incident hypertension (12 957 person-years), 589 cardiovascular disease (60 300 person-years), and 195 chronic kidney disease (47 370 person-years) events on follow-up. Obesity and being metabolically unhealthy were independently and positively associated with all outcomes. BMI variability, compared with stable BMI, was associated with 163%, 67%, 58%, and 74% higher risks of having obesity, becoming metabolically unhealthy, having diabetes mellitus, and having hypertension, respectively, among nonobese participants. Variable metabolic health, compared with stable metabolic health, was associated with a 28% higher risk of cardiovascular disease, among metabolically healthy participants. Conclusions We did not observe evidence for a positive interaction between obesity and metabolic health status with regard to study outcomes. BMI and metabolic health variability are associated with adverse health outcomes.

Visit-to-visit blood pressure variability and risk of chronic kidney disease: A systematic review and meta-analyses

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.

Variability in estimated glomerular filtration rate and the incidence of type 2 diabetes: a nationwide population-based study

OBJECTIVE

Variability in estimated glomerular filtration rate (eGFR) has been associated with adverse outcomes in patients with diabetes or chronic kidney disease (CKD). However, no previous study has explored the relationship between eGFR variability and type 2 diabetes incidence.

RESEARCH DESIGN AND METHODS

In this nationwide, longitudinal, cohort study, we investigated the association between eGFR variability and type 2 diabetes risk using the Korean National Health Insurance Service datasets from 2002 to 2017. eGFR variability was calculated using the variability independent of the mean (eGFR-VIM), coefficient of variation (eGFR-CV), standard deviation (eGFR-SD) and average real variability (eGFR-ARV).

RESULTS

Within 7 673 905.58 person-years of follow-up (mean follow-up: 3.19 years; n=2 402 668), 11 981 cases of incident type 2 diabetes were reported. The HRs and 95% CIs for incident type 2 diabetes increased according to advance in quartiles of eGFR-VIM (HR (95% CI): Q2, 1.068 (1.009 to 1.130); Q3, 1.077 (1.018 to 1.138); Q4, 1.203 (1.139 to 1.270)) even after adjusting for confounding factors including mean eGFR and mean fasting plasma glucose levels. The subgroup analyses according to risk factors as well as analyses using eGFR-CV, eGFR-SD and eGFR-ARV showed consistent results. The association between increased eGFR variability and type 2 diabetes risk was more prominent in men, individuals with dyslipidemia and those with CKD as shown in the subgroup analysis (p for interaction <0.001).

CONCLUSIONS

Increased eGFR variability may be an independent predictor of type 2 diabetes and might be useful for risk stratification of individuals without diabetes.

Proteinuria is independently associated with the incidence of primary cardiovascular events in diabetic patients

BACKGROUND

Albuminuria is a risk factor for cardiovascular events in diabetic patients, but it is unknown whether proteinuria is also a risk factor for cardiovascular events in these patients.

METHODS

The Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) trial was performed between 2002 and 2008 to examine the efficacy of low-dose aspirin therapy for the primary prevention of cardiovascular events in type 2 diabetes patients. After the JPAD trial was completed, we continued to follow up the patients until 2015. Among the 2536 patients participating in the JPAD study, 42 were excluded because proteinuria was not checked at registration. We divided the patients into two groups: proteinuria group (n = 446; proteinuria ± or greater) and non-proteinuria groups (n = 2048; proteinuria -). We compared the incident rate of cardiovascular events between the two groups.

RESULTS

During the observation period [median, 10.3 (10.2-10.5) years], 332 patients had a first cardiovascular event. Among 332 patients, 136 patients had cerebrovascular events and 54 patients had acute myocardial infarction. The incidence rate of cardiovascular events was significantly higher in the proteinuria group compared with the non-proteinuria group (HR 1.75, 95%CI 1.36-2.23, p < 0.0001). The incidence rate of cerebrovascular events was also significantly higher in the proteinuria group than in the non-proteinuria group (HR 1.71, 95%CI 1.14-2.49, p = 0.0064). The Cox proportional hazards model revealed that proteinuria was independently associated with cardiovascular events in diabetic patients without a history of cardiovascular events after adjusting for age, gender, body mass index, hemoglobin A1c level, duration of diabetes, and estimated glomerular filtration rate.

CONCLUSIONS

Proteinuria was independently associated with the incidence of primary cardiovascular events in diabetic patients. Proteinuria detected by the dipstick test, which is simple and inexpensive, is useful as a first step in the risk assessment of diabetic patients.

Association of systolic blood pressure and pulse pressure with microalbuminuria in treatment-naïve hypertensive patients

INTRODUCTION

To investigate the association between blood pressure components and microalbuminuria (MAU) in newly diagnosed and treatment-naïve hypertensive patients.

MATERIAL AND METHODS

A total of 1858 newly diagnosed and treatment-naïve hypertensive patients were enrolled. Based on 24 h urine albumin concentration, all patients were divided into MAU and normo-albuminuria groups. The associations between blood pressure (BP) components, namely systolic/diastolic BP (SBP/DBP) and pulse pressure (PP) and MAU, as well as the sensitivity and specificity of each BP component in predicting MAU, were evaluated.

RESULTS

Compared to the normo-albuminuria group, patients in the MAU group were older and had significantly higher SBP and PP (p < 0.05). Serum levels of fasting blood glucose, total protein and creatinine were significantly higher in the MAU group (p < 0.05). 24-hour urine albumin excretion was significantly higher in the MAU group than the normo-albuminuria group (182.5 ±156.5 mg vs. 17.6 ±7.1 mg, p < 0.001). Logistic regression analyses revealed that SBP and PP were significantly associated with MAU, with an odds ratio (OR) of 1.010 (95% confidence interval (CI): 1.005-1.016, p < 0.001) in SBP and OR of 1.009 (95% CI: 1.003-1.015, p = 0.003) in PP. The receiver operating characteristic curve showed that the area under the curve for SBP to predict MAU was 0.541 ±0.013, and PP was 0.536 ±0.013. The difference in predicting MAU by SBP or PP was non-significant.

CONCLUSIONS

In newly diagnosed and treatment-naïve hypertensive patients, increased SBP and PP were independently associated with MAU.

Fast eating is a strong risk factor for new-onset diabetes among the Japanese general population

Although many studies that have examined the relationship of type and amount of food and the frequency of eating with new onset of diabetes, there are few reports on the relationship between how meals are eaten, such as skipping breakfast, snacking or food ingestion speed, and the onset of diabetes. We investigated the relationship between eating speed, as well as other eating habits such as snacking and skip breakfast, and new onset of diabetes in a nation-wide Japanese cohort. We obtained data from the nation-wide annual health check program in Japan. In 197,825 participants without diabetes in 2008, questionnaires recorded data on the diet habits (eating speed, snack after supper or before sleep, and skipping breakfast) and unadjusted and multivariable-adjusted logistic regression models were used to measure the odds ratio of new-onset diabetes mellitus in a 3-year follow up. The proportion of fast eaters, those who snack after supper, snack before sleep, and skip breakfast was higher in the new-onset diabetes group than in the group who did not develop diabetes mellitus. As compared with the non-fast eater group, fast eaters were generally younger, had higher BMI, had more weight gain from 20 years onwards, and experienced frequent weight fluctuations of ≥3 kg within 1 year. The risk of fast eaters developing diabetes mellitus remained even after correction for multiple factors including age, body weight, rate of weight change, blood pressure, smoking, and alcohol consumption. No other eating habits were independent predictors for onset of diabetes mellitus. Results show that fast eating is a sole predisposing factor among eating habits for new-onset diabetes. Future studies were warranted to evaluate whether avoidance of fast eating is beneficial for prevention of diabetes mellitus.

Blood pressure variability in individuals with and without (pre)diabetes: The Maastricht Study

OBJECTIVE

The mechanisms associating (pre)diabetes and cardiovascular disease (CVD) are incompletely understood. We hypothesize that greater blood pressure variability (BPV) may underlie this association, due to its association with (incident) CVD. Therefore, we investigated the association between (pre)diabetes and very short-term to mid-term BPV, that is within-visit, 24-h and 7-day BPV.

METHODS

Cross-sectional data from The Maastricht Study [normal glucose metabolism (NGM), n = 1924; prediabetes, n = 511; type 2 diabetes mellitus (T2DM), n = 975; 51% men, aged 60 ± 8 years]. We determined SD for within-visit BPV (n = 3244), average real variability for 24-h BPV (n = 2699) day (0900-2100 h) and night (0100-0600 h) separately, and SD for 7-day BPV (n = 2259). Differences in BPV as compared with NGM were assessed by multiple linear regressions with adjustment for potential confounders.

RESULTS

In T2DM, the average systolic/diastolic values of within-visit, 24-h and 7-day BPV were 4.8/2.6, 10.5/7.3 and 10.4/6.5 mmHg, respectively, and in prediabetes 4.9/2.6, 10.3/7.0 and 9.4/5.9 mmHg, respectively. T2DM was associated with greater nocturnal systolic BPV [0.42 mmHg (95% confidence interval: 0.05-0.80)], and greater 7-day systolic [0.76 mmHg (0.32-1.19)] and diastolic BPV [0.65 mmHg (0.29-1.01)], whereas prediabetes was associated with greater within-visit systolic BPV only [0.35 mmHg (0.06-0.65)], as compared with NGM.

CONCLUSION

Both T2DM and prediabetes are associated with slightly greater very short-term to mid-term BPV, which may, according to previous literature, explain a small part of the increased CVD risk seen in (pre)diabetes. Nevertheless, these findings do not detract from the fact that very short-term to mid-term BPV is substantial and important in individuals with and without (pre)diabetes.

Long-term blood pressure variability and development of chronic kidney disease in type 2 diabetes

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.

Labile hypertension: a new disease or a variability phenomenon?

Blood pressure (BP) is a physiological parameter with short- and long-term variability caused by complex interactions between intrinsic cardiovascular (CV) mechanisms and extrinsic environmental and behavioral factors. Available evidence suggests that not only mean BP values are important, but also BP variability (BPV) might contribute to CV events. Labile hypertension (HTN) is referred to sudden rises in BP and it seems to be linked with unfavorable outcomes. The aim of this article was to review and summarize recent evidence on BPV phenomenon, unraveling the labile HTN concept along with the prognostic value of these conditions.

Low fasting plasma glucose level as a predictor of new-onset diabetes mellitus on a large cohort from a Japanese general population

Although fasting plasma glucose levels <70 mg/dL are associated with a high incidence of cardiovascular disease (CVD), whether there is any risk of new-onset diabetes mellitus owing to fasting plasma glucose at this range has not been clarified. We measured the odds ratio (OR) of new-onset diabetes mellitus relative to fasting plasma glucose levels at various ranges in a nation-wide Japanese population with and without CVD history. Of 186,749 participants without diabetes in 2008, 171,408 had no history of CVD, while 15,341 did. Participants were classified into 8 categories according to their fasting plasma glucose levels. Unadjusted and multivariable-adjusted logistic regression models were used to measure the OR of new-onset diabetes mellitus in the 3-year follow up. In all participants, multivariable-adjusted OR increased when fasting plasma glucose levels were <70 mg/dL or 90–125 mg/dL. Participants without CVD showed increased OR when glucose levels were <70 mg/dL or 90–125 mg/dL. Participants with a history of CVD showed increased OR with glucose levels of 95–125 mg/dL. The risk of new-onset diabetes mellitus is higher when fasting glucose levels are <70 mg/dL, indicating that the paradox of fasting glucose seeks a new risk stratification for new-onset diabetes mellitus.

Peak lung function during young adulthood and future long-term blood pressure variability: The Coronary Artery Risk Development in Young Adults (CARDIA) study

BACKGROUND AND AIMS

Long-term blood pressure variability (BPV) is associated with cardiovascular events independent of mean blood pressure (BP); however, little is known about its predictors.

METHODS

Using data from the CARDIA study, we investigated the association between peak lung-function and long-term BPV in 2917 individuals (mean age 24.8 years, 45.3% males, 58.6% whites) who were not taking antihypertensive medications. Lung-function was measured using forced vital capacity (FVC) and forced expiratory volume in 1-s (FEV1) at years 0, 2, 5, 10 and 20 and the maximum score attained was considered as peak lung-function. Variability independent of the mean (VIM) and coefficient of variation (CV) of BP were calculated to quantify BPV since achieving peak lung-function across 9 visits over 30 years.

RESULTS

In a multivariate linear regression models, individuals in the 2nd (-0.64 mmHg; 95% CI: -1.06, -0.19), 3rd (-0.96; -1.47, -0.45), and 4th (-0.85: -1.53, -0.17) quartiles of FVC had lower VIM of systolic BP than the those in quartile 1 (p-trend = 0.005). CV of systolic BP was also lower by -0.58 (-0.98, -0.19), -0.92 (-1.42, -0.43), and -0.74 (-1.40, -0.08) percentage points, in the three progressively higher quartiles of FVC compared to quartile 1 (p-trend = 0.008). Similar findings were observed when the outcome was diastolic BPV. There was no association of FEV1 and FEV1-to-FVC ratio with BPV.

CONCLUSIONS

These findings suggest that smaller lung volume or restrictive lung disease during young adulthood, which result in lower peak FVC, may independently increase the risk of higher long-term BPV during middle adulthood.

Dipstick proteinuria and all-cause mortality among the general population

BACKGROUND

Dipstick proteinuria, but not albuminuria, is used for general health screening in Japan. How the results of dipstick proteinuria tests correlate with mortality and, however, is not known.

METHODS

Subjects were participants of the 2008 Tokutei-Kenshin (Specific Health Check and Guidance program) in six districts in Japan. On the basis of the national database of death certificates from 2008 to 2012, we used a personal identifier in two computer registries to identify participants who might have died. The hazard ratio (95% confidence interval, CI) was calculated by Cox-proportional hazard analysis.

RESULTS

Among a total of 140,761 subjects, we identified 1641 mortalities that occurred by the end of 2012. The crude mortality rates were 1.1% for subjects who were proteinuria (-), 1.5% for those with proteinuria (+/-), 2.0% for those with proteinuria (1+), 3.5% for those with proteinuria (2+), and 3.7% for those with proteinuria (≥ 3+). After adjusting for sex, age, body mass index, estimated glomerular filtration rate, comorbid condition, past history, and lifestyle, the hazard ratio (95% CI) for dipstick proteinuria was 1.262 (1.079-1.467) for those with proteinuria (+/-), 1.437 (1.168-1.748) for those with proteinuria (1+), 2.201 (1.688-2.867) for those with proteinuria (2+), and 2.222 (1.418-3.301) for those with proteinuria (≥ 3+) compared with the reference of proteinuria (-).

CONCLUSION

Dipstick proteinuria is an independent predictor of death among Japanese community-based screening participants.

Impaired Glucose Metabolism Is Associated with Visit-to-Visit Blood Pressure Variability in Participants without Cardiovascular Disease

We evaluated data from 10,088 participants without cardiovascular disease (CVD) who underwent 75 g oral glucose tolerance tests and had more than four visits during the first 5 years following the test to investigate the association between impaired glucose metabolism and visit-to-visit blood pressure (BP) variability. Participants were classified into groups of normal glucose tolerance (NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and diabetes. Visit-to-visit BP variability was estimated for each individual using standard deviation (SD) and coefficients of variation (CV, defined as SD/mean). SDs and CVs of systolic BP (SBP) values were divided into quartiles. The samples falling in the highest quartile were considered as having high SD/CV. The adjusted odds ratio (OR) for high SD of SBP in the IFG (OR, 1.39; P < 0.003), IGT (OR, 1.26; P < 0.001), and diabetes (OR, 1.54; P < 0.001) groups was significantly higher than that for high SD of SBP in the NGT group. Similarly, the OR for high CV of SBP in the IGT and diabetes groups was significantly higher than that for high CV of SBP in the NGT group. In participants without CVD, impaired glucose metabolism may modulate visit-to-visit BP variability.

Visit-to-visit blood pressure variability in children and adolescents with renal disease

BACKGROUND

Increase in blood pressure (BP) variability (BPV) is associated with cardiovascular events, target organ damage, and arterial stiffness in adults. We previously reported that 24-h BPV may be associated with arterial stiffness and underlie white-coat hypertension (WCH). In this study, we examined whether visit-to-visit variability (VVV) could predict WCH and whether VVV correlated with eGFR, eGFR slope, and albuminuria/proteinuria in children and adolescents with renal diseases.

METHODS

VVV was determined as average real variability of office BP measurements between visits, and 24-h BPV as the standard deviation of 24-h ambulatory BP. In 35 renal patients (25 boys and 10 girls, 7-18 years of age), divided into normotension (NT), WCH, and hypertension (HTN), the relationships between VVV and 24-h BPV and VVV in each BP category were studied. In separate 48 renal patients (24 boys and 24 girls, 2-18 years of age), the correlation between VVV and eGFR, eGFR slope, urine albumin or protein excretion was examined.

RESULTS

Systolic VVV was significantly correlated with systolic office BP index. There was no correlation between VVV and 24-h BPV or 24-h pulse pressure. In addition, VVV was not different among NT, WCH, and HTN. Systolic VVV was significantly negatively correlated with eGFR but not with eGFR slope, albuminuria, or proteinuria. A cut-off value of systolic VVV for detecting eGFR < 60 ml/min per 1.73 m² was 8.5.

CONCLUSION

VVV could not predict WCH. Systolic VVV correlated with eGFR but not with eGFR slope, albuminuria/proteinuria. Increased VVV could be a marker of decreased eGFR.

Exaggerated blood pressure variability is associated with memory impairment in very elderly patients

We investigated the association between working memory (WM) impairment and blood pressure variability (BPV) in very elderly patients. Japanese outpatients ≥80 years who engaged in normal activities of daily living were the study cohort. WM function was evaluated by a simple visual WM test consisting of 3 figures. We considered the number of figures recalled by the patient his/her test score. We defined the patients with a score of 0 or 1 as those with WM impairment and those with scores of 2 or 3 as those without. To investigate the relative risk of WM impairment, we evaluated each patient's 24 hour ambulatory systolic blood pressure (SBP) and its weighted standard deviation (SD_SBP ), office SBP, and the visit-to-visit SD_SBP during the 1 year period from the patient's enrollment. A total of 66 patients (mean 84 ± 3.6 years) showed WM impairment, and 431 patients (mean 83 ± 3.1 years) showed no WM impairment. There were no significant differences in 24 hour ambulatory SBP or office SBP between these two groups. However, the WM impairment patients showed significantly higher weighted SD_SBP and visit-to-visit SD_SBP values compared to the no-impairment group even after adjusting for age. Among these ≥80-year-old patients, those with the highest quartile of both weighted SD_SBP (≥21.4 mm Hg) and visit-to-visit SD_SBP (≥14.5 mm Hg) showed the highest relative risk (odds ratio 3.52, 95% confidence interval 1.42-8.72) for WM impairment. Exaggerated blood pressure variability parameters were significantly associated with working memory impairment in very elderly individuals.

Association between within-visit systolic blood pressure variability and development of pre-diabetes and diabetes among overweight/obese individuals

Short-term blood pressure variability is associated with pre-diabetes/diabetes cross-sectionally, but there are no longitudinal studies evaluating this association. The objective of this study is to evaluate the association between within-visit systolic and diastolic blood pressure variability and development of pre-diabetes/diabetes longitudinally. The study was conducted among eligible participants from the San Juan Overweight Adults Longitudinal Study (SOALS), who completed the 3-year follow-up exam. Participants were Hispanics, 40-65 years of age, and free of diabetes at baseline. Within-visit systolic and diastolic blood pressure variability was defined as the maximum difference between three measures, taken a few minutes apart, of systolic and diastolic blood pressure, respectively. Diabetes progression was defined as development of pre-diabetes/diabetes over the follow-up period. We computed multivariate incidence rate ratios adjusting for baseline age, gender, smoking, physical activity, waist circumference, and hypertension status. Participants with systolic blood pressure variability ≥10 mmHg compared to those with <10 mmHg, showed higher progression to pre-diabetes/diabetes (RR = 1.77, 95% CI: 1.30-2.42). The association persisted among never smokers. Diastolic blood pressure variability ≥10 mmHg (compared to <10 mmHg) did not show an association with diabetes status progression (RR = 1.20, 95% CI: 0.71-2.01). Additional adjustment of baseline glycemia, C-reactive protein, and lipids (reported dyslipidemia or baseline HDL or triglycerides) did not change the estimates. Systolic blood pressure variability may be a novel independent risk factor and an early predictor for diabetes, which can be easily incorporated into a single routine outpatient visit at none to minimal additional cost.

Blood Pressure and Visit-to-Visit Blood Pressure Variability Among Individuals With Primary Proteinuric Glomerulopathies

Hypertension and blood pressure variability (BPV; SD and average real variability) in primary proteinuric glomerulopathies are not well described. Data were from 433 participants in the NEPTUNE (Nephrotic Syndrome Study Network). Hypertensive BP status was defined as previous history of hypertension or BP ≥140/90 mm Hg for adults/≥95th percentile for children at baseline. BPV was measured in participants with ≥3 visits in the first year. Two-hundred ninety-six adults (43 years [interquartile range, 32-57.8 years], 61.5% male) and 147 children (11 years [interquartile range, 5-14 years], 57.8% male) were evaluated. At baseline, 64.8% of adults and 46.9% of children were hypertensive. Histological diagnosis was associated with hypertensive status in adults (P=0.036). In adults, hypertensive status was associated with lower hazard of complete remission (hazard ratio, 0.36; 95% confidence interval, 0.19-0.68) and greater hazard of achieving the composite end point (end-stage renal disease or estimated glomerular filtration rate decline >40%; hazard ratio, 4.1; 95% confidence interval, 1.4-12). Greater systolic and diastolic SD and average real variability were also associated with greater hazard of reaching the composite end point in adults (all P<0.01). In children, greater BPV was an independent predictor of composite end point (determined by systolic SD and average real variability) and complete remission (determined by systolic and diastolic average real variability; all P<0.05). Hypertensive status was common among adults and children enrolled in NEPTUNE. Differences in hypertensive status prevalence, BPV, and treatment were found by age and histological diagnosis. In addition, hypertensive status and greater BPV were associated with poorer clinical outcomes.

The impact of evacuation on the incidence of chronic kidney disease after the Great East Japan Earthquake: The Fukushima Health Management Survey

Background

About 146,000 people were forced into long-term evacuation due to the nuclear power plant accident caused by the Great East Japan Earthquake in 2011. Disaster is known to induce hypertension in survivors for a certain period, but it is unclear whether prolonged disaster stress influences chronic kidney disease (CKD). We conducted an observational cohort study to elucidate the effects of evacuation stress on CKD incidence.

Methods

Participants were individuals living in communities near the Fukushima nuclear power plant, aged 40–74 years without CKD as of their 2011 general health checkup (non-evacuees: n = 9780, evacuees: n = 4712). We followed new-onset CKD [estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² or proteinuria] using general annual health checkup data from 2012 to 2014. Association between evacuation and CKD incidence was analyzed using the Cox proportional hazard model.

Results

Mean age of the participants at baseline was 65 years, 46.7% were men, and baseline eGFR was 75.7 ml/min/1.73 m². During the mean follow-up period of 2.46 years, CKD incidence rate was 80.8/1000 and 100.2/1000 person-years in non-evacuees and evacuees, respectively. Evacuation was a significant risk factor of CKD incidence after adjusting for age, gender, obesity, hypertension, diabetes, dyslipidemia, smoking, and baseline eGFR [hazard ratio (HR): 1.45; 95% confidence interval (CI) 1.35–1.56]. Evacuation was significantly associated with the incidence of eGFR <60 ml/min/1.73 m² (HR: 1.48; 95% CI 1.37–1.60), but not with the incidence of proteinuria (HR: 1.21; 95% CI 0.93–1.56).

Conclusion

Evacuation was a risk factor associated with CKD incidence after the disaster.

Mortality risk among screened subjects of the specific health check and guidance program in Japan 2008-2012

BACKGROUND

In Japan, the Specific Health Check and Guidance (Tokutei-Kenshin) has started in 2008. However, the relationship between the baseline characteristics and mortality has not been examined.

METHODS

Subjects were those who participated at the 2008 Tokutei-Kenshin in six districts with baseline data of serum creatinine. Using National database of death certificate from 2008 to 2012, we identified those who might have died and confirmed further with the collaborations of the regional National Health Insurance agency and public health nurses. The data was released to the research team supported by the Ministry of Health, Labor, and Welfare of Japan, and is governed by strict regulation and is completely encrypted with the individual's name and residence. Causes of death were classified by ICD-10.

RESULTS

Among the total of 295,297 subjects, we identified 3764 fatal cases by end of 2012. The median BMI was 23.8 kg/m² in men and 22.5 kg/m² in women, respectively. Proteinuria, dipstick 1+ and over, was positive in 5.3%. The median eGFR was 73.8 ml/min/1.73 m² among those with data available in 81% of the total cohort (N = 239,274). The leading cause of death was neoplasm in both genders. It was 51.6% of the total, 50.4% in men and 53.7% in women. The second cause of death was circulatory; 20.4% of the total, 21.1% in men and 19.2% in women.

CONCLUSION

Half of the causes of death was related to neoplasm among the cohort of the Tokutei-Kenshin. Effects of baseline demographics such as lifestyle and CKD remained to be studied.

Arterial pressure lability is improved by sodium-glucose cotransporter 2 inhibitor in streptozotocin-induced diabetic rats

To prevent cardiovascular events in patients with diabetes mellitus (DM), it is essential to reduce arterial pressure (AP). Sodium-glucose cotransporter 2 inhibitor (SGLT2i) prevents cardiovascular events via the depressor response in patients with DM. In the present study, we examined whether SGLT2i ameliorates AP lability in DM rats. Ten-week-old male Sprague-Dawley rats were administered a single intravenous injection of streptozotocin (50 mg kg^-1) and were divided into three groups treated with low-dose SGLT2i, vehicle (VEH) or subcutaneously implanted insulin pellets (SGLT2i, VEH and Insulin group, respectively) for 14 days. SGLT2i reduced blood glucose, but its effect was lower than that of insulin. The telemetered mean AP at the end of the experiment did not differ among the SGLT2i, Insulin and VEH groups (83±7 vs. 98±9 vs. 90±8 mm Hg, respectively, n=5 for each). The standard deviation of AP as the index of lability was significantly smaller during the active period in the SGLT2i group than in the VEH group (5.6±0.5 vs. 7.0±0.7 mm Hg, n=5 for each, P<0.05). Sympathetic nerve activity during the active period was significantly lower in the SGLT2i group than in the VEH group. Baroreflex sensitivity (BRS) was significantly higher in the SGLT2i group than in the VEH group. The standard deviation of AP and sympathoexcitation did not differ between the Insulin and VEH groups. In conclusion, SGLT2i at a non-depressor dose ameliorated the AP lability associated with sympathoinhibition during the active period and improved the BRS in streptozotocin-induced DM rats.

Association Between Long-Term Blood Pressure Variability and 10-Year Progression in Arterial Stiffness: The Multiethnic Study of Atherosclerosis

Experimental studies conducted on animal and human endothelium suggested that higher systolic blood pressure (SBP) variability reduces bioavailability of nitric oxide and increases vascular smooth muscle cell proliferation. These vascular wall changes could stiffen the arterial wall. Using data from the Multiethnic Study of Atherosclerosis, we investigated the association between long-term SBP variability and 10-year percent change in arterial stiffness among 1122 individuals (mean age 57 years, 46% males at baseline) who were not taking antihypertensive medications. Within-individual standard deviation, variability independent of the mean, and coefficient of variation of SBP across 5 visits were used to capture long-term SBP variability. Carotid arterial stiffness was measured using distensibility coefficient and Young's elastic modulus at baseline and after a mean of 9.5 years of follow-up (visit 5). In a multivariate linear regression model, individuals in the fifth quintile as compared with those in the first quintile of standard deviation, variability independent of the mean, and coefficient of variation of SBP had a 9.8% (95% confidence interval [CI] -17.0%, -2.7%), 6.4% (95% CI -13.2%, 0.4%), and 8.7% (95% CI -15.4%, -1.9%) higher decline in distensibility coefficient and a 27.5% (95% CI 15.8%, 39.3%), 25.8% (95% CI 14.7%, 36.9%), and 27.9% (95% CI 16.8%, 39.1%) higher progression in Young's elastic modulus, respectively, after 10 years of follow-up. Linear trends in the decline of distensibility coefficient and progression of Young's elastic modulus were observed across the quintiles of SBP variability indices. These findings suggest that higher long-term SBP variability may be a risk factor for arterial stiffness progression independent of mean BP.

Long-Term Visit-to-Visit Blood Pressure Variability and Renal Function Decline in Patients With Hypertension Over 15 Years

BACKGROUND

Visit-to-visit variability of systolic blood pressure (SBP) has been shown to contribute to cardiovascular events and all-cause mortality. However, little is known about its long-term effect on renal function. We aim to examine the relationship between visit-to-visit blood pressure variability (BPV) and decline in renal function in patients with hypertension and to determine the level of systolic BPV that is associated with significant renal function decline.

METHODS AND RESULTS

This is a 15-year retrospective cohort study of 825 hypertensive patients. Blood pressure readings every 3 months were retrieved from the 15 years of clinic visits. We used SD and coefficient of variation as a measure of systolic BPV. Serum creatinine was captured and estimated glomerular filtration rate was calculated at baseline, 5, 10, and 15 years. The mean SD of SBP was 14.2±3.1 mm Hg and coefficient of variation of SBP was 10.2±2%. Mean for estimated glomerular filtration rate slope was -1.0±1.5 mL/min per 1.73 m2 per year. There was a significant relationship between BPV and slope of estimated glomerular filtration rate (SD: r=-0.16, P<0.001; coefficient of variation: r=-0.14, P<0.001, Pearson's correlation). BPV of SBP for each individual was significantly associated with slope of estimated glomerular filtration rate after adjustment for mean SBP and other confounders. The cutoff values estimated by the receiver operating characteristic curve for the onset of chronic kidney disease for SD of SBP was 13.5 mm Hg and coefficient of variation of SBP was 9.74%.

CONCLUSIONS

Long-term visit-to-visit variability of SBP is an independent determinant of renal deterioration in patients with hypertension. Hence, every effort should be made to reduce BPV in order to slow down the decline of renal function.

Association of Systolic Blood Pressure Variability With Mortality, Coronary Heart Disease, Stroke, and Renal Disease

BACKGROUND

Intraindividual blood pressure (BP) fluctuates dynamically over time. Previous studies suggested an adverse link between greater visit-to-visit variability in systolic blood pressure (SBP) and various outcomes. However, these studies have significant limitations, such as a small size, inclusion of selected populations, and restricted outcomes.

OBJECTIVES

This study investigated the association of increased visit-to-visit variability and all-cause mortality, cardiovascular events, and end-stage renal disease (ESRD) in a large cohort of U.S. veterans.

METHODS

From among 3,285,684 U.S. veterans with and without hypertension and normal estimated glomerular filtration rates (eGFR) during 2005 and 2006, we identified 2,865,157 patients who had 8 or more outpatient BP measurements. Systolic blood pressure variability (SBPV) was measured using the SD of all SBP values (normally distributed) in 1 individual. Associations of SD quartiles (<10.3, 10.3 to 12.7, 12.7 to 15.6, and ≥15.6 mm Hg) with all-cause mortality, incident coronary heart disease (CHD), stroke, and ESRD was examined using Cox models adjusted for sociodemographic characteristics, baseline eGFR, comorbidities, body mass index, SBP, diastolic BP, and antihypertensive medication use.

RESULTS

Several sociodemographic variables (older age, male sex, African-American race, divorced or widowed status) and clinical characteristics (lower baseline eGFR, higher SBP and diastolic BP), and comorbidities (presence of diabetes, hypertension, cardiovascular disease, and lung disease) were all associated with higher intraindividual SBPV. The multivariable adjusted hazard ratios and 95% confidence intervals for SD quartiles 2 through 4 (compared with the first quartile) associated with all-cause mortality, CHD, stroke, and ESRD were incrementally higher.

CONCLUSIONS

Higher SBPV in individuals with and without hypertension was associated with increased risks of all-cause mortality, CHD, stroke, and ESRD. Further studies are needed to determine interventions that can lower SBPV and their impact on adverse health outcomes.

Regional Fat Distribution and Blood Pressure Level and Variability: The Dallas Heart Study

Our aim was to investigate the associations of regional fat distribution with home and office blood pressure (BP) levels and variability. Participants in the Dallas Heart Study, a multiethnic cohort, underwent 5 BP measurements on 3 occasions during 5 months (2 in home and 1 in office) and quantification of visceral adipose tissue, abdominal subcutaneous adipose tissue, and liver fat by magnetic resonance imaging, and lower body subcutaneous fat by dual x-ray absorptiometry. The relation of regional adiposity with short-term (within-visit) and long-term (overall visits) mean BP and average real variability was assessed with multivariable linear regression. We have included 2595 participants with a mean age of 44 years (54% women; 48% black), and mean body mass index was 29 kg/m(2) Mean systolic BP/diastolic BP was 127/79 mm Hg and average real variability systolic BP was 9.8 mm Hg during 3 visits. In multivariable-adjusted models, higher amount of visceral adipose tissue was associated with higher short-term (both home and office) and long-term mean systolic BP (β[SE]: 1.9[0.5], 2.7[0.5], and 2.1[0.5], respectively; all P<0.001) and with lower long-term average real variability systolic BP (β[SE]: -0.5[0.2]; P<0.05). In contrast, lower body fat was associated with lower short-term home and long-term mean BP (β[SE]: -0.30[0.13] and -0.24[0.1], respectively; both P<0.05). Neither subcutaneous adipose tissue or liver fat was associated with BP levels or variability. In conclusion, excess visceral fat was associated with persistently higher short- and long-term mean BP levels and with lower long-term BP variability, whereas lower body fat was associated with lower short- and long-term mean BP. Persistently elevated BP, coupled with lower variability, may partially explain increased risk for cardiac hypertrophy and failure related to visceral adiposity.

Visit-to-Visit Variability of BP and CKD Outcomes: Results from the ALLHAT

BACKGROUND AND OBJECTIVES

Increased visit-to-visit variability of BP is associated with cardiovascular disease risk. We examined the association of visit-to-visit variability of BP with renal outcomes among 21,245 participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We measured mean BP and visit-to-visit variability of BP, defined as SD, across five to seven visits occurring 6-28 months after participants were randomized to chlorthalidone, amlodipine, or lisinopril. The composite outcome included incident ESRD after assessment of SD of systolic BP or ≥50% decline in eGFR between 24 months and 48 or 72 months after randomization. We repeated the analyses using average real variability and peak value of systolic BP and for visit-to-visit variability of diastolic BP.

RESULTS

Over a mean follow-up of 3.5 years, 297 outcomes occurred. After multivariable adjustment, including baseline eGFR and mean systolic BP, the hazard ratios for the composite end point were 1.29 (95% confidence interval [95% CI], 0.75 to 2.22), 1.76 (95% CI, 1.06 to 2.91), 1.46 (95% CI, 0.88 to 2.45), and 2.05 (95% CI, 1.25 to 3.36) for the second through fifth (SD of systolic BP =6.63-8.82, 8.83-11.14, 11.15-14.56, and >14.56 mmHg, respectively) versus the first (SD of systolic BP <6.63 mmHg) quintile of SD of systolic BP, respectively (P trend =0.004). The association was similar when ESRD and a 50% decline in eGFR were analyzed separately, for other measures of visit-to-visit variability of systolic BP, and for visit-to-visit variability of diastolic BP.

CONCLUSIONS

Higher visit-to-visit variability of BP is associated with higher risk of renal outcomes independent of mean BP.

Central blood pressure and chronic kidney disease

In this review, we focused on the relationship between central blood pressure and chronic kidney diseases (CKD). Wave reflection is a major mechanism that determines central blood pressure in patients with CKD. Recent medical technology advances have enabled non-invasive central blood pressure measurements. Clinical trials have demonstrated that compared with brachial blood pressure, central blood pressure is a stronger risk factor for cardiovascular (CV) and renal diseases. CKD is characterized by a diminished renal autoregulatory ability, an augmented direct transmission of systemic blood pressure to glomeruli, and an increase in proteinuria. Any elevation in central blood pressure accelerates CKD progression. In the kidney, interstitial inflammation induces oxidative stress to handle proteinuria. Oxidative stress facilitates atherogenesis, increases arterial stiffness and central blood pressure, and worsens the CV prognosis in patients with CKD. A vicious cycle exists between CKD and central blood pressure. To stop this cycle, vasodilator antihypertensive drugs and statins can reduce central blood pressure and oxidative stress. Even in early-stage CKD, mineral and bone disorders (MBD) may develop. MBD promotes oxidative stress, arteriosclerosis, and elevated central blood pressure in patients with CKD. Early intervention or prevention seems necessary to maintain vascular health in patients with CKD.

Effects of ACEIs Versus ARBs on Proteinuria or Albuminuria in Primary Hypertension: A Meta-Analysis of Randomized Trials

Although angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) belong to a family of therapies that block the renin-angiotensin system and are suggested to improve proteinuria/albuminuria, it is unclear which is more effective. To compare the effects of ACEIs and ARBs on proteinuria in primary hypertension by performing a meta-analysis covering randomized controlled trials (RCTs). We systematically searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from January 1990 to November 2014. Eligible studies were RCTs of ACEI therapy versus ARB therapy that reported the albumin excretion rate (AER), albumin (Alb), and urinary albumin excretion (UAE) as outcomes. Seventeen RCTs, including 17,951 patients (without limit of race, age, or sex) with a mean duration of 62.6 weeks, were included. Pooled analysis suggested that ACEIs and ARBs showed no significant differences in AER/Alb/UAE/24-h urine protein/24-h urine total protein in a comparison of 10 trials (SMD 0.09; 95% CI -0.18-0.36; P = 0.52). No significant differences were observed in urinary protein/creatinine ratio (UPCR)/urinary albumin/creatinine ratio (UACR), or albumin/creatinine ratio (ACR) in 7 trials (SMD 0.15; 95% CI -1.88-2.19; P = 0.88). The total outcome of ACEIs and ARBs also showed no significant difference (SMD 0.13; 95% CI -1.03-1.29; P = 0.83). The efficacies of ACEIs and ARBs in controlling blood pressure as a secondary indicator were also similar (SMD -0.50; 95% CI -1.58-0.58; P = 0.37). Based on a meta-analysis of 17 randomized controlled trials including 17,951 patients, we found that ACEIs and ARBs can reduce urine protein levels, improve blood pressure, and were similarly effective in terms of reducing urinary protein excretion.