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Ku E, Jamerson K, Copeland TP, McCulloch CE, Tighiouart H, Sarnak MJ. Acute Declines in Estimated Glomerular Filtration Rate in Patients Treated With Benazepril and Hydrochlorothiazide Versus Amlodipine and Risk of Cardiovascular Outcomes. J Am Heart Assoc 2024; 13:e035177. [PMID: 39056339 DOI: 10.1161/jaha.124.035177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Acute declines in estimated glomerular filtration rate (eGFR) occur commonly after starting angiotensin-converting enzyme inhibitors. Whether declines in eGFR that occur after simultaneously starting angiotensin-converting enzyme inhibitors with other antihypertensive agents modifies the benefits of these agents on cardiovascular outcomes is unclear. METHODS AND RESULTS We identified predictors of acute declines in eGFR (>15% over 3 months) during randomization to benazepril plus amlodipine versus benazepril plus hydrochlorothiazide in the ACCOMPLISH (Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension) trial. We then determined the relation between declines in eGFR (treated as a binary variable, ≤15% versus >15% and separately, as a restricted spline variable) and the composite risk of fatal and nonfatal cardiovascular events using Cox proportional hazards models. We included 10 714 participants (median age 68 years [Q1 63, Q3 73]), of whom 1024 reached the trial end point over median follow-up of 2.8 years. Predictors of acute declines in eGFR>15% over 3 months included assignment to hydrochlorothiazide (versus amlodipine) and higher baseline albuminuria. Overall, declines in eGFR ≥15% (versus <15%) were associated with a 26% higher hazard of cardiovascular outcomes (95% CI, 1.07-1.48). In spline-based analysis, risk for cardiovascular outcomes was higher in the hydrochlorothiazide arm at every level of decline in eGFR compared with the same magnitude of eGFR decline in the amlodipine arm. CONCLUSION Combined use of benazepril and amlodipine remains superior to benazepril and hydrochlorothiazide for cardiovascular outcomes, regardless of the magnitude of the decline in eGFR that occurred with initiation of therapy.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine University of California San Francisco CA
- Department of Epidemiology & Biostatistics University of California San Francisco CA
| | - Kenneth Jamerson
- Department of Medicine, Division of Cardiovascular Medicine University of Michigan Ann-Arbor Ann-Arbor MI
| | - Timothy P Copeland
- Division of Nephrology, Department of Medicine University of California San Francisco CA
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics University of California San Francisco CA
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies Tufts Medical Center Boston MA
- Tufts Clinical and Translational Science Institute Tufts University Boston MA
| | - Mark J Sarnak
- Tufts Clinical and Translational Science Institute Tufts University Boston MA
- Division of Nephrology, Department of Medicine Tufts University Boston MA
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Ku E, McCulloch CE, Copeland TP, Inker LA, Tighiouart H, Sarnak MJ. Acute Declines in Estimated GFR in Blood Pressure Target Trials and Risk of Adverse Outcomes. Am J Kidney Dis 2023; 82:454-463. [PMID: 37269972 DOI: 10.1053/j.ajkd.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 03/10/2023] [Indexed: 06/05/2023]
Abstract
RATIONALE & OBJECTIVE Acute decreases in glomerular filtration rate (GFR) occur commonly during intensive blood pressure (BP) lowering. Our objective was to determine the relationship between acute decreases in estimated GFR and patient outcomes. STUDY DESIGN Retrospective observational study. SETTING & PARTICIPANTS Participants from 4 randomized controlled trials of intensive BP lowering in chronic kidney disease (Modification of Diet in Renal Disease study, African American Study of Kidney Disease and Hypertension, Systolic Blood Pressure Intervention Trial, and Action to Control Cardiovascular Risk in Diabetes trial). EXPOSURE A 4-category exposure defined by the level of acute decrease in estimated GFR (defined as>15% vs≤15% between baseline and month 4) and the randomization to intensive versus usual BP control. OUTCOMES Risk of kidney replacement therapy (primary outcome), defined as the need for dialysis or transplant except in the Action to Control Cardiovascular Risk in Diabetes trial, which defined its kidney outcome as a composite occurrence of serum creatinine concentration>3.3mg/dL, kidney failure, or kidney replacement therapy. ANALYTICAL APPROACH Multivariable Cox models. RESULTS We included 4,473 individuals randomly assigned to intensive versus usual BP control who had a total of 351 kidney outcomes and 304 deaths during median follow-up durations of 22 and 24 months, respectively. Approximately 14% of participants exhibited an acute decrease in eGFR, 11.0% in the usual BP treatment arm and 17.8% in the intensive BP treatment arm. In adjusted models, compared with a≤15% eGFR decrease in the usual BP arm, a≤15% eGFR decrease in the intensive BP control arm was associated with lower risk of the kidney outcome (HR, 0.75; 95% CI, 0.57-0.98). In contrast, a>15% decrease in eGFR was associated with a higher risk of the kidney outcome in the usual (HR, 2.47; 95% CI, 1.80-3.38) and intensive BP treatment arms (HR, 1.99; 95% CI, 1.45-2.73) compared with a≤15% decrease in the usual BP arm. LIMITATIONS Observational study, residual confounding. CONCLUSIONS Decreases in eGFR of>15% in the usual and intensive BP treatment arms were associated with a higher risk of kidney outcomes compared with a≤15% decrease in the usual BP arm and may be a harbinger of adverse outcomes.
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Affiliation(s)
- Elaine Ku
- Department of Medicine, Division of Nephrology, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA.
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Timothy P Copeland
- Department of Medicine, Division of Nephrology, University of California San Francisco, San Francisco, CA
| | - Lesley A Inker
- Department of Medicine, Division of Nephrology, Boston, MA
| | - Hocine Tighiouart
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Mark J Sarnak
- Department of Medicine, Division of Nephrology, Boston, MA
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Okada R, Tsushita K, Wakai K, Kato K, Wada T, Shinohara Y. Healthy lifestyle reduces incidence of trace/positive proteinuria and rapid kidney function decline after 2 years: from the Japan Ningen Dock study. Nephrol Dial Transplant 2021; 36:1039-1048. [PMID: 33247759 DOI: 10.1093/ndt/gfaa224] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/15/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Lifestyle modification is recommended for subjects with trace proteinuria during health checkups. However, whether overall healthy lifestyle reduces the incidence of trace/positive proteinuria or rapid decline in estimated glomerular filtration rate (eGFR) is not clarified. METHODS A total of 451 534 people (277 494 men and 174 040 women) ages 20-79 years with negative proteinuria were included. The number of three healthy lifestyle factors (LFs) was assessed: noncurrent smoking, healthy eating habits (late dinner, snacking and skipping breakfast <3 times/week) and body mass index <25. The incidence of trace (±) and positive (≥1+) proteinuria by the dipstick method and eGFR decline ≥20% over 2 years were compared with the number of healthy LFs. RESULTS The incidence of trace/positive proteinuria and rapid eGFR decline decreased with an increasing number of healthy LFs as follows: odds ratios (ORs) for trace proteinuria, 0.91 [95% confidence interval (CI) 0.86-0.96], 0.82 (0.78-0.87) and 0.72 (0.68-0.77); ORs for positive proteinuria, 0.76 (95% CI 0.67-0.86), 0.56 (0.50-0.63) and 0.46 (0.40-0.53); and ORs for an eGFR decline ≥20%, 0.93 (95% CI 0.82-1.05), 0.90 (0.79-1.02) and 0.81 (0.70-0.93) for those with one, two and three healthy LFs compared with those with none of the three healthy LFs, respectively. Overall, subjects with a healthy lifestyle showed 28, 54 and 19% reduced risk of developing trace proteinuria, positive proteinuria and eGFR decline ≥20%, respectively, compared with those with an unhealthy lifestyle after 2 years. This association was similarly observed even among subjects without hypertension (HT) or diabetes mellitus (DM). CONCLUSIONS Subjects with an overall healthy lifestyle showed a lower incidence of trace/positive proteinuria by dipstick test and rapid eGFR decline over 2 years in a nationwide general population. Thus lifestyle modification should be recommended for subjects with trace proteinuria during health checkups, even for subjects without HT or DM.
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Affiliation(s)
- Rieko Okada
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kazuyo Tsushita
- Comprehensive Health Science Center, Aichi Health Promotion Foundation, Aichi, Japan
| | - Kenji Wakai
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kiminori Kato
- Department of Laboratory Medicine and Clinical Epidemiology for Prevention of Noncommunicable Diseases, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Takashi Wada
- Health Science, Jikei University Graduate School of Medicine, Tokyo, Japan
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Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW, Tomson CR, Mann JF. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int 2021; 99:S1-S87. [PMID: 33637192 DOI: 10.1016/j.kint.2020.11.003] [Citation(s) in RCA: 404] [Impact Index Per Article: 134.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
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Chen DC, McCallum W, Sarnak MJ, Ku E. Intensive BP Control and eGFR Declines: Are These Events Due to Hemodynamic Effects and Are Changes Reversible? Curr Cardiol Rep 2020; 22:117. [PMID: 32772196 DOI: 10.1007/s11886-020-01365-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Acute declines in estimated glomerular filtration rate (eGFR) are often observed during intensive blood pressure (BP) lowering. This review focuses on identifying the various mechanisms of eGFR decline associated with intensive BP lowering and evaluates the evidence linking BP control with kidney and cardiovascular (CV) outcomes. RECENT FINDINGS In 2017, the American College of Cardiology and the American Heart Association (ACC/AHA) began recommending treatment of all individuals to a BP target of < 130/80 mmHg. Since then, multiple post hoc analyses of BP trials have associated intensive BP lowering with acute declines in kidney function and acute kidney injury; whether these represent reversible changes in the kidney is still debated. There is ample evidence that intensive BP lowering is associated with declines in eGFR. The clinical implications of these events remain unclear. Individualizing the risks and benefits of intensive BP therapy continues to be warranted.
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Affiliation(s)
- Debbie C Chen
- Division of Nephrology, Department of Medicine, University of California San Francisco, 533 Parnassus Ave, U404, San Francisco, CA, 94143-0532, USA.
| | - Wendy McCallum
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Mark J Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Elaine Ku
- Division of Nephrology, Department of Medicine, University of California San Francisco, 533 Parnassus Ave, U404, San Francisco, CA, 94143-0532, USA.,Division of Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
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Collard D, Brouwer TF, Olde Engberink RH, Zwinderman AH, Vogt L, van den Born BJH. Initial Estimated Glomerular Filtration Rate Decline and Long-Term Renal Function During Intensive Antihypertensive Therapy: A Post Hoc Analysis of the SPRINT and ACCORD-BP Randomized Controlled Trials. Hypertension 2020; 75:1205-1212. [PMID: 32223381 PMCID: PMC7176351 DOI: 10.1161/hypertensionaha.119.14659] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 01/23/2019] [Accepted: 01/28/2020] [Indexed: 01/13/2023]
Abstract
Lowering blood pressure (BP) can lead to an initial decline in estimated glomerular filtration rate (eGFR). However, there is debate how much eGFR decline is acceptable. We performed a post hoc analysis of ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes-Blood Pressure) and SPRINT (Systolic Blood Pressure Intervention Trial), which randomized patients to intensive or standard systolic BP-targets. We determined the relation between initial decline in mean arterial pressure and eGFR. Subsequently, we stratified patients to BP-target and initial eGFR decrease and assessed the relation with annual eGFR decline after 1 year. A total of 13 266 patients with 41 126 eGFR measurements were analyzed. Up to 10 mm Hg of BP-lowering, eGFR did not change. Hereafter, there was a linear decrease of 3.4% eGFR (95% CI, 2.9%-3.9%) per 10 mm Hg mean arterial pressure decrease. The observed eGFR decline based on 95% of the subjects varied from 26% after 0 mm Hg to 46% with a 40 mm Hg mean arterial pressure decrease. There was no difference in eGFR slope (P=0.37) according to initial eGFR decline and BP-target, with a decrease of 1.24 (95% CI, 1.09-1.39), 1.20 (95% CI, 0.97-1.43), and 1.14 (95% CI, 0.77-1.50) in the 5%, 5% to 20%, and >20% stratum during intensive and 0.95 (95% CI, 0.81-1.09), 1.23 (95% CI, 0.97-1.49), and 1.17 (95% CI, 0.65-1.69) mL/minute per 1.73 m2 per year during standard treatment. In patients at high cardiovascular risk with and without diabetes mellitus, we found no association between initial eGFR and annual eGFR decline during BP-lowering treatment. Our results support that an eGFR decrease up to 20% after BP lowering can be accepted and suggest that the limit can be extended up to 46% depending on the achieved BP reduction. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00000620, NCT01206062.
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Affiliation(s)
- Didier Collard
- From the Department of Vascular Medicine (D.C., B.-J.H.v.d.B.), Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Tom F. Brouwer
- Department of Clinical and Experimental Cardiology (T.F.B.), Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Rik H.G. Olde Engberink
- Department of Nephrology (R.H.G.O.E., L.V.), Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Aeilko H. Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics (A.E.Z.), Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Nephrology (R.H.G.O.E., L.V.), Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Bert-Jan H. van den Born
- From the Department of Vascular Medicine (D.C., B.-J.H.v.d.B.), Amsterdam UMC, University of Amsterdam, The Netherlands
- Department of Public Health (B.-J.H.v.d.B.), Amsterdam UMC, University of Amsterdam, The Netherlands
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Blood pressure targets in chronic kidney disease: an update on the evidence. Curr Opin Nephrol Hypertens 2020; 29:327-332. [PMID: 32167996 DOI: 10.1097/mnh.0000000000000601] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Hypertension is the leading modifiable cause of cardiovascular events and of mortality and is generally considered as a direct cause of chronic kidney disease. Defining optimal blood pressure targets in patients with chronic kidney disease is therefore of critical importance. RECENT FINDINGS Over the recent years, results and post-hoc analyses of several important trials comparing blood pressure targets which included patients with chronic kidney disease have been published. Although these results provide important means to understand the consequences of high blood pressure and to improve the management of hypertension in chronic kidney disease, they led to remarkably different interpretations and recommendations in the current guidelines. SUMMARY The present review summarizes the current evidence and areas of controversy for the definition of blood pressure targets in patients with chronic kidney disease.
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Duni A, Dounousi E, Pavlakou P, Eleftheriadis T, Liakopoulos V. Hypertension in Chronic Kidney Disease: Novel Insights. Curr Hypertens Rev 2019; 16:45-54. [PMID: 30987570 DOI: 10.2174/1573402115666190415153554] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 12/13/2022]
Abstract
Management of arterial hypertension in patients with chronic kidney disease (CKD) remains a major challenge due to its high prevalence and associations with cardiovascular disease (CVD) and CKD progression. Several clinical trials and meta-analyses have demonstrated that aggressive treatment of hypertension in patients with and without CKD lowers the risk of CVD and all-cause mortality, nevertheless the effects of blood pressure (BP) lowering in terms of renal protection or harm remain controversial. Both home and ambulatory BP estimation have shown that patients with CKD display abnormal BP patterns outside of the office and further investigation is required, so as to compare the association of ambulatory versus office BP measurements with hard outcomes and adjust treatment strategies accordingly. Although renin-angiotensin system blockade appears to be beneficial in patients with advanced CKD, especially in the setting of proteinuria, discontinuation of renin-angiotensin system inhibition should be considered in the setting of frequent episodes of acute kidney injury or hypotension while awaiting the results of ongoing trials. In light of the new evidence in favor of renal denervation in arterial hypertension, the indications and benefits of its application in individuals with CKD need to be clarified by future studies. Moreover, the clinical utility of the novel players in the pathophysiology of arterial hypertension and CKD, such as microRNAs and the gut microbiota, either as markers of disease or as therapeutic targets, remains a subject of intensive research.
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Affiliation(s)
- Anila Duni
- Department of Nephrology, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Evangelia Dounousi
- Department of Nephrology, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Paraskevi Pavlakou
- Department of Nephrology, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | | | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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James MT, Levey AS, Tonelli M, Tan Z, Barry R, Pannu N, Ravani P, Klarenbach SW, Manns BJ, Hemmelgarn BR. Incidence and Prognosis of Acute Kidney Diseases and Disorders Using an Integrated Approach to Laboratory Measurements in a Universal Health Care System. JAMA Netw Open 2019; 2:e191795. [PMID: 30951162 PMCID: PMC6450331 DOI: 10.1001/jamanetworkopen.2019.1795] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 02/18/2019] [Indexed: 12/29/2022] Open
Abstract
Importance Abnormal measurements of kidney function or structure may be identified that do not meet criteria for acute kidney injury (AKI) or chronic kidney disease (CKD) but nonetheless may require medical attention. The Kidney Disease: Improving Global Outcomes Clinical Practice Guideline for AKI proposed criteria for the definition of acute kidney diseases and disorders (AKD), which include AKI; however, the incidence and prognosis of AKD without AKI remain unknown. Objective To characterize the incidence and outcomes of AKD without AKI, with or without CKD. Design, Setting, and Participants Retrospective cohort study including all adult residents in a universal health care system in Alberta, Canada, without end-stage kidney disease (ESKD) and with at least 1 serum creatinine measurement between January 1 and December 31, 2008, in a community or hospital setting. Data analysis took place in 2018. Main Outcomes and Measures The Kidney Disease: Improving Global Outcomes guideline definitions for CKD, AKI, and AKD based on serum creatinine, estimated glomerular filtration rate, and albuminuria criteria were applied to estimate the proportion of patients with CKD, AKI, and AKD without AKI, and combinations of the conditions. Patients were followed up for up to 8 years (study end date, June 31, 2016) to characterize their risks of mortality, development of new CKD, progression of preexisting CKD, and ESKD. Results Among 1 109 099 Alberta residents included in the cohort, the mean (SD) age was 52.3 (17.6) years, and 43.0% were male. Findings showed that AKD without AKI was common (3.8 individuals without preexisting CKD and 0.6 with preexisting CKD per 100 population tested). In Cox proportional hazards and competing risks models over a median (interquartile range) of 6.0 (5.7-6.3) years of follow-up, AKD without AKI (compared with no kidney disease) was associated with higher risks of developing new CKD (37.4% vs 7.4%%; adjusted sub-hazard ratio [sHR], 3.17; 95% CI, 3.10-3.23), progression of preexisting CKD (49.5% vs 34.6%; adjusted sHR, 1.38; 95% CI, 1.33-1.44), ESKD (0.6% vs 0.1%; adjusted sHR, 8.56; 95% CI, 7.32-10.01), and death (25.8% vs 7.3%; adjusted hazard ratio, 1.42; 95% CI, 1.39-1.45). Conclusions and Relevance Criteria for AKD identified many patients who did not meet the criteria for CKD or AKI but had overall modestly increased risks of incident and progressive CKD, ESKD, and death. The clinical importance of AKD remains to be determined.
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Affiliation(s)
- Matthew T. James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Zhi Tan
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Rebecca Barry
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Neesh Pannu
- Department of Medicine, University of Alberta, Alberta, Canada
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Braden J. Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Alberta, Canada
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11
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Chang AR, Lóser M, Malhotra R, Appel LJ. Blood Pressure Goals in Patients with CKD: A Review of Evidence and Guidelines. Clin J Am Soc Nephrol 2018; 14:161-169. [PMID: 30455322 PMCID: PMC6364532 DOI: 10.2215/cjn.07440618] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hypertension affects the vast majority of patients with CKD and increases the risk of cardiovascular disease, ESKD, and death. Over the past decade, a number of hypertension guidelines have been published with varying recommendations for BP goals in patients with CKD. Most recently, the American College of Cardiology/American Heart Association 2017 hypertension guidelines set a BP goal of <130/80 mm Hg for patients with CKD and others at elevated cardiovascular risk. These guidelines were heavily influenced by the landmark Systolic Blood Pressure Intervention Trial (SPRINT), which documented that an intensive BP goal to a systolic BP <120 mm Hg decreased the risk of cardiovascular disease and mortality in nondiabetic adults at high cardiovascular risk, many of whom had CKD; the intensive BP goal did not retard CKD progression. It is noteworthy that SPRINT measured BP with automated devices (5-minute wait period, average of three readings) often without observers, a technique that potentially results in BP values that are lower than what is typically measured in the office. Still, results from SPRINT along with long-term follow-up data from the Modification of Diet in Renal Disease and the African American Study of Kidney Disease and Hypertension suggest that a BP goal <130/80 mm Hg will reduce mortality in patients with CKD. Unfortunately, data are more limited in patients with diabetes or stage 4-5 CKD. Increased adverse events, including electrolyte abnormalities and decreased eGFR, necessitate careful laboratory monitoring. In conclusion, a BP goal of <130/80 is a reasonable, evidence-based BP goal in patients with CKD. Implementation of this intensive BP target will require increased attention to measuring BP accurately, assessing patient preferences and concurrent medical conditions, and monitoring for adverse effects of therapy.
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Affiliation(s)
- Alex R Chang
- Kidney Health Research Institute, Geisinger Health System, Danville, Pennsylvania;
| | - Meghan Lóser
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Rakesh Malhotra
- Division of Nephrology and Hypertension, University of California San Diego, San Diego, California; and
| | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
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12
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Walther CP, Shah M, Navaneethan SD. Estimated GFR Decline and Tubular Injury Biomarkers With Intensive Blood Pressure Control. Am J Kidney Dis 2018; 73:4-7. [PMID: 30424915 DOI: 10.1053/j.ajkd.2018.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/12/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Maulin Shah
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
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