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Shi X, Shi Y, Fan L, Yang J, Chen H, Ni K, Yang J. Prognostic value of oxygen saturation index trajectory phenotypes on ICU mortality in mechanically ventilated patients: a multi-database retrospective cohort study. J Intensive Care 2023; 11:59. [PMID: 38031107 PMCID: PMC10685672 DOI: 10.1186/s40560-023-00707-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Heterogeneity among critically ill patients undergoing invasive mechanical ventilation (IMV) treatment could result in high mortality rates. Currently, there are no well-established indicators to help identify patients with a poor prognosis in advance, which limits physicians' ability to provide personalized treatment. This study aimed to investigate the association of oxygen saturation index (OSI) trajectory phenotypes with intensive care unit (ICU) mortality and ventilation-free days (VFDs) from a dynamic and longitudinal perspective. METHODS A group-based trajectory model was used to identify the OSI-trajectory phenotypes. Associations between the OSI-trajectory phenotypes and ICU mortality were analyzed using doubly robust analyses. Then, a predictive model was constructed to distinguish patients with poor prognosis phenotypes. RESULTS Four OSI-trajectory phenotypes were identified in 3378 patients: low-level stable, ascending, descending, and high-level stable. Patients with the high-level stable phenotype had the highest mortality and fewest VFDs. The doubly robust estimation, after adjusting for unbalanced covariates in a model using the XGBoost method for generating propensity scores, revealed that both high-level stable and ascending phenotypes were associated with higher mortality rates (odds ratio [OR]: 1.422, 95% confidence interval [CI] 1.246-1.623; OR: 1.097, 95% CI 1.027-1.172, respectively), while the descending phenotype showed similar ICU mortality rates to the low-level stable phenotype (odds ratio [OR] 0.986, 95% confidence interval [CI] 0.940-1.035). The predictive model could help identify patients with ascending or high-level stable phenotypes at an early stage (area under the curve [AUC] in the training dataset: 0.851 [0.827-0.875]; AUC in the validation dataset: 0.743 [0.709-0.777]). CONCLUSIONS Dynamic OSI-trajectory phenotypes were closely related to the mortality of ICU patients requiring IMV treatment and might be a useful prognostic indicator in critically ill patients.
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Affiliation(s)
- Xiawei Shi
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Yangyang Shi
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Liming Fan
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia Yang
- The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China
| | - Hao Chen
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Kaiwen Ni
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Junchao Yang
- The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China.
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2
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Xu Q, Shen Y, Zhao J, Shen J. Salvianolate injection for hypertensive nephropathy patients who were using valsartan: A systematic review and meta-analysis. Front Pharmacol 2023; 14:1119150. [PMID: 36794275 PMCID: PMC9922779 DOI: 10.3389/fphar.2023.1119150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/18/2023] [Indexed: 02/01/2023] Open
Abstract
Background: The treatment of hypertensive nephropathy has remained unchanged for many years. Salvianolate is the main active component extracted from Salvia Miltiorrhiza. The current studies seem to suggest that salvianolate has a certain therapeutic effect on hypertensive nephropathy. Objective: The purpose of this meta-analysis is to evaluate the effect and safety of salvianolate on hypertensive nephropathy under the condition of standardized use of valsartan. Methods: We conducted a systematic search (unlimited initial date to 22 October 2022) in PubMed, Web of Science, the Cochrane Library, Embase, China National Knowledge Infrastructure, Wanfang Data knowledge service platform, China Science and Technology Journal Database, China Biomedical Literature Service System. Searching for the study of salvianolate on hypertensive nephropathy. Two reviewers independently included the study that met the inclusion criteria, and extracted data, evaluated the quality of the study. We use RevMan5.4 and stata15 software for this meta-analysis. We use GRADEprofiler 3.2.2 software for evidence quality assessment. Results: This meta-analysis included seven studies (525 patients). Compared with the use of valsartan combined with conventional treatment, salvianolate combined with valsartan and conventional treatment can further improve the efficacy (RR = 1.28, 95%CI:1.17 to 1.39), reduce blood pressure [systolic blood pressure (MD = 8.98, 95%CI:-12.38 to -5.59); diastolic blood pressure (MD = 5.74, 95%CI:-7.20 to -4.29)], serum creatinine (MD = -17.32, 95%CI:-20.55 to -14.10), blood urea nitrogen (MD = -1.89, 95%CI:-3.76 to -0.01), urine microalbumin (MD = -23.90, 95%CI:-26.54 to -21.26), and urinary protein to creatinine ratio (MD = -1.92, 95%CI:-2.15 to -1.69), cystatin C (MD = -1.04, 95%CI: -1.63 to -0.45) and increase calcitonin gene-related peptide (MD = 18.68, 95%CI:12.89 to 24.46) without increasing adverse reactions (RR = 2.20, 95%CI:0.52 to 9.40). But it has no additional effect on endothelin-1 and malondialdehyde. The quality of evidence ranged from moderate to very low. Conclusion: This meta-analysis shows that the salvianolate can further improve renal function of hypertensive nephropathy patients based on valsartan was used. Therefore, salvianolate can be used as a clinical supplement for hypertensive nephropathy. However, the quality of the evidence is not high due to the uneven quality of the included studies and the insufficient sample size, we still need a lot of large sample size studies with more perfect design to confirm these results. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022373256, identifier CRD42022373256.
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Affiliation(s)
- Qiyao Xu
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China,Graduate School, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yuehong Shen
- School of Chinese Medicine, School of Integrated Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jianqiao Zhao
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China,Graduate School, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jianping Shen
- Graduate School, Nanjing University of Chinese Medicine, Nanjing, China,*Correspondence: Jianping Shen,
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Rios P, Sola L, Ferreiro A, Silvariño R, Lamadrid V, Ceretta L, Gadola L. Adherence to multidisciplinary care in a prospective chronic kidney disease cohort is associated with better outcomes. PLoS One 2022; 17:e0266617. [PMID: 36240220 PMCID: PMC9565398 DOI: 10.1371/journal.pone.0266617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 03/23/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The Renal Healthcare Program Uruguay (NRHP-UY) is a national, multidisciplinary program that provides care to chronic kidney disease (CKD) patients. In this study, we report the global results of CKD patient outcomes and a comparison between those treated at the NRHP-UY Units, with those patients who were initially included in the program but did not adhere to follow up. METHODS A cohort of not-on dialysis CKD patients included prospectively in the NRHP-UY between October 1st 2004 and September 30th 2017 was followed-up until September 30th 2019. Two groups were compared: a) Nephrocare Group: Patients who had at least one clinic visit during the first year on NRHP-UY (n = 11174) and b) Non-adherent Group: Patients who were informed and accepted to be included but had no subsequent data registered after admission (n = 3485). The study was approved by the Ethics Committee and all patients signed an informed consent. Outcomes were studied with Logistic and Cox´s regression analysis, Fine and Gray competitive risk and propensity-score matching tests. RESULTS 14659 patients were analyzed, median age 70 (60-77) years, 56.9% male. The Nephrocare Group showed improved achievement of therapeutic goals, ESKD was more frequent (HR 2.081, CI 95%1.722-2.514) as planned kidney replacement therapy (KRT) start (OR 2.494, CI95% 1.591-3.910), but mortality and the combined event (death and ESKD) were less frequent (HR 0.671, CI95% 0.628-0.717 and 0.777, CI95% 0.731-0.827) (p = 0.000) compared to the Non-adherent group. Results were similar in the propensity-matched group: ESKD (HR 2.041, CI95% 1.643-2.534); planned kidney replacement therapy (KRT) start (OR 2.191, CI95% 1.322-3.631) death (HR 0.692, CI95% 0.637-0.753); combined event (HR 0.801, CI95% 0.742-0.865) (p = 0.000). CONCLUSION Multidisciplinary care within the NRHP-UY is associated with timely initiation of KRT and lower mortality in single outcomes, combined analysis, and propensity-matched analysis.
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Affiliation(s)
- Pablo Rios
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
| | - Laura Sola
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
| | - Alejandro Ferreiro
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
- Departamento de Nefrología, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Ricardo Silvariño
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
- Departamento de Nefrología, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Verónica Lamadrid
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
| | - Laura Ceretta
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
| | - Liliana Gadola
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
- Departamento de Nefrología, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
- * E-mail:
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Fu H, Hou W, Zhang Y, Hu X. Alprostadil for hypertensive nephropathy: A systematic review and meta-analysis of randomized controlled trials. PLoS One 2022; 17:e0269111. [PMID: 35617324 PMCID: PMC9135256 DOI: 10.1371/journal.pone.0269111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/15/2022] [Indexed: 11/25/2022] Open
Abstract
We performed a meta-analysis to evaluate the efficacy of alprostadil in the treatment of hypertensive nephropathy. Seven online databases (PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure [CNKI] database, Wanfang Data Knowledge Service Platform, VIP Information Resource Integration Service Platform [cqVIP], and China Biology Medicine Disc [SinoMed]) were searched from inception to January 31, 2022, and a set of clinical indicators for hypertensive nephropathy was selected. The main indicators were 24-h urinary protein, serum creatinine, endogenous serum creatinine clearance rate, blood urea nitrogen, cystatin C, and mean arterial pressure. The methodological quality of the included trials was analyzed using a risk of bias assessment according to the Cochrane Manual guidelines, and a meta-analysis was performed. A random-effects model was implemented to pool the results. A total of 20 randomized controlled trials involving 1441 patients with hypertensive nephropathy were included in this review. Our findings showed that alprostadil had a positive effect on 24-h urinary protein (mean difference [MD] = −0.79, 95% confidence interval [CI] [−1.16, −0.42], P < 0.0001), serum creatinine (MD = −13.83, 95% CI [−19.34, −8.32], P < 0.00001), endogenous serum creatinine clearance rate (MD = 6.09, 95% CI [3.59, 8.59], P < 0.00001), blood urea nitrogen (MD = −6.42, 95% CI [−8.63, −4.21], P < 0.00001), cystatin C (MD = −0.26, 95% CI [−0.34, −0.18], P < 0.00001), and mean arterial pressure levels(MD = −13.65, 95% CI [−16.08, −11.21], P < 0.00001). Compared to conventional treatment alone, alprostadil combined with conventional treatment can improve renal function in patients with hypertensive nephropathy more effectively. However, additional large-scale, multicenter, rigorously designed randomized controlled trials are needed to verify these results. This is the first meta-analysis to evaluate the efficacy of alprostadil for hypertensive nephropathy, and the results may guide clinical practice.
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Affiliation(s)
- Hongfang Fu
- Infectious Disease Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, People’s Republic of China
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, People’s Republic of China
| | - Weiwei Hou
- Emergency Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, People’s Republic of China
| | - Yang Zhang
- Infectious Disease Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, People’s Republic of China
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, People’s Republic of China
| | - Xiaoyu Hu
- Infectious Disease Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, People’s Republic of China
- * E-mail:
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5
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McFadden CB. Update in Hypertension. Med Clin North Am 2022; 106:259-267. [PMID: 35227429 DOI: 10.1016/j.mcna.2021.11.003] [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] [Indexed: 11/25/2022]
Abstract
The treatment of elevated blood pressure (BP) can improve cardiovascular (CV) event rates. Current BP targets depend on expected CV event rates in individuals as assessed by concurrent medical conditions and other risk factors. Importantly, the means by which BP is measured has evolved. This evolution is driven by recognition that techniques different than routine office BP measurements can provide a better assessment of future CV risk.
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Affiliation(s)
- Christopher B McFadden
- Department of Medicine, Cooper Medical School of Rowan University, 401 Haddon Avenue, Room 280, Camden, NJ 08103, USA.
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6
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Salvador VD, Bakris GL. Taking a step back: Making sense of evidence on diastolic blood pressure in the context of targets for older adults. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100079. [PMID: 38560062 PMCID: PMC10978199 DOI: 10.1016/j.ahjo.2021.100079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Vincent D. Salvador
- AHA Comprehensive Hypertension Center, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - George L. Bakris
- AHA Comprehensive Hypertension Center, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
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7
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Chen Z, Peng Y, Yang F, Qiang X, Chen Y, Chen Y, Cao L, Liu C, Zhang J. Traditional Chinese Medicine Injections Combined With Antihypertensive Drugs for Hypertensive Nephropathy: A Network Meta-Analysis. Front Pharmacol 2021; 12:740821. [PMID: 34744724 PMCID: PMC8570188 DOI: 10.3389/fphar.2021.740821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/11/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Hypertension, a risk factor for cardiovascular events, is often associated with chronic kidney disease. This is called hypertensive nephropathy (HN), which negatively affects physical fitness and body mass, leading to economic burden. Traditional Chinese medicine injections (TCMIs) are common traditional Chinese-patent medicine preparations in China. There was a lack of evidence to prove which TCMIs combine with ADs (TCMIs+ADs) may be a therapeutic option for HN. Thus, we systematically reviewed the efficacy and safety of various TCMIs + ADs in patients with HN. Methods: We conducted a comprehensive search of PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, and VIP information resource integration service platform databases for relevant Chinese- and English-language randomized controlled trials (RCTs) published from database inception until May 2021. Literature screening, data extraction, and quality assessment was performed by two reviewers independently but using the same criteria. We performed the effect modeling to analyze the data for all outcomes and ranked each intervention using the P-score. Furthermore, sensitivity analysis, meta-regression, and funnel plots were used to test the stability, heterogeneity, and publication bias, respectively. Results: We included 69 RCTs with 6373 patients and including six TCMIs + ADs. Network analysis indicated that the ginkgo leaf extract and dipyridamole combined with ADs (GLED + ADs) was the most efficacious in terms of 24-h urinary protein excretion [mean difference (MD) = −0.70, 95% confidence interval (CI): −0.82 to −0.58; P-score = 1] and systolic blood pressure (MD = −12.95, 95% CI: −21.03 to −4.88; P-score = 0.88), whereas the salvianolate combined with ADs (SA + ADs) showed the highest effectiveness for diastolic blood pressure (MD = −6.88, 95% CI: −10.55 to −3.21; P-score = 0.9). Based on the combined P-score of network meta-analysis results (88% and 85.26%) and sensitivity analysis results (72% and 71.54%), the biplots showed that the GLED + ADs was the most efficacious intervention in all TCMIs + ADs for primary outcomes, followed by the SA + ADs and sodium tanshinone IIA sulfonate combined with ADs (STS + ADs). There was no significant difference in terms of safety between TCMIs + ADs and ADs alone. Conclusion: Of all the TCMIs + ADs, GLED + ADs, SA + ADs, and STS + ADs may demonstrate a higher efficacy than ADs alone for HN. Weighing with the potential benefits and limitations in methodology, potential heterogeneity and outcomes, we should use various TCMIs with caution in clinical practice. Nevertheless, additional high-quality RCTs are warranted and future research should focus on the clinical value of core outcomes to confirm the effectiveness and safety of TCMIs for HN. Systematic Review Registration: clinicaltrials.gov, identifier CRD42020205358
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Affiliation(s)
- Zhe Chen
- Evidence-based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yingying Peng
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China.,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Fengwen Yang
- Evidence-based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xiaoyu Qiang
- Evidence-based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yong Chen
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yongjie Chen
- Department of Epidemiology and Statistic, School of Public Health, Tianjin Medical University, Tianjin, China
| | - Lujia Cao
- Evidence-based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Chunxiang Liu
- Evidence-based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Junhua Zhang
- Evidence-based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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8
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Zhuo M, Yang D, Goldfarb-Rumyantzev A, Brown RS. The association of SBP with mortality in patients with stage 1-4 chronic kidney disease. J Hypertens 2021; 39:2250-2257. [PMID: 34232158 PMCID: PMC8500924 DOI: 10.1097/hjh.0000000000002927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Hypertension is a risk factor for chronic kidney disease (CKD) progression and mortality. However, the optimal blood pressure associated with decreased mortality in each stage of CKD remains uncertain. METHODS In this retrospective cohort study, we included 13 414 individuals with CKD stages 1-4 from NHANES general population datasets from 1999 to 2004 followed to 31 December 2010. Multivariate analysis and Kaplan--Meier curves were used to assess SBP and risk factors associated with overall mortality in each CKD stage. RESULTS In these individuals with death rates of 9, 12, 30 and 54% in baseline CKD stages 1 through 4, respectively, SBP less than 100 mmHg was associated with significantly increased mortality adjusted for age, sex and race in stages 2,3,4. After excluding less than 100 mmHg, as a continuous variable, higher SBP is associated with fully adjusted increased mortality risk in those on or not on antihypertensive medication (hazard ratio 1.006, P = 0.0006 and hazard ratio 1.006 per mmHg, P < 0.0001, respectively). In those on antihypertensive medication, SBP less than 100 mmHg or in each 20 mmHg categorical group more than 120 mmHg is associated with an adjusted risk of increased mortality. Increasing age, men, smoking, diabetes and comorbidities are associated with increased mortality risk. CONCLUSION For patients with CKD stages 1-4, the divergence of SBP above or below 100-120 mmHg was found to be associated with higher all-cause mortality, especially in those patients on antihypertensive medication. These findings support the recent guideline of an optimal target goal SBP of 100-120 mmHg in patients with CKD stages 1-4.
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Affiliation(s)
- Min Zhuo
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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9
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Lee JY, Park JT, Joo YS, Lee C, Yun HR, Chang TI, Kim YH, Chung W, Yoo TH, Kang SW, Park SK, Chae DW, Oh KH, Han SH. Association of Blood Pressure with Cardiovascular Outcome and Mortality: Results from the KNOW-CKD Study. Nephrol Dial Transplant 2021; 37:1722-1730. [PMID: 34473286 DOI: 10.1093/ndt/gfab257] [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: 05/18/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Optimal BP control is a major therapeutic strategy to reduce adverse cardiovascular events and mortality in patients with CKD. We studied the association of BP with adverse cardiovascular outcome and all-cause death in patients with CKD. METHODS Among 2,238 participants from the KoreaN cohort study for Outcome in patients With CKD, 2,226 patients with baseline BP measurements were enrolled. Main predictor was SBP categorized by 5 levels: <110, 110-119, 120-129, 130-139, and ≥140 mmHg. Primary endpoint was a composite outcome of all-cause death or incident cardiovascular events. We primarily used marginal structural models using averaged and the most recent time-updated SBPs. RESULTS During a median follow-up of 10233.79 person-years (median 4.60 years), the primary composite outcome occurred in 240 (10.8%) participants, with a corresponding incidence rate of 23.5 (95% CI, 20.7-26.6) per 1,000 patient-years. Marginal structural models with averaged SBP showed a U-shaped relationship with the primary outcome. Compared to time-updated SBP of 110-119 mmHg, hazard ratios (95% CI) for <110, 120-129, 130-139, and ≥140 mmHg were 2.47 (1.48-4.11), 1.29 (0.80-2.08), 2.15 (1.26-3.69), and 2.19 (1.19-4.01), respectively. Marginal structural models with the most recent SBP also showed similar findings. CONCLUSIONS In Korean patients with CKD, there was a U-shaped association of SBP with the risk of adverse clinical outcome. Our findings highlight the importance of BP control and suggest a potential hazard of SBP <110 mmHg.
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Affiliation(s)
- Jee Young Lee
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Young Su Joo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Changhyun Lee
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Hae-Ryong Yun
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Yeong-Hoon Kim
- Department of Nephrology, Busan Paik Hospital, College of Medicine, Inje University, Busan, 614-735, South Korea
| | - WooKyung Chung
- Department of Internal Medicine, Gil Medical Center, Gachon University, Incheon, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Sue K Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Wan Chae
- Department of Internal Medicine, Seoul National University Hospital, Kidney Research Institute, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Kidney Research Institute, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
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Shen R, Gao M, Tao Y, Chen Q, Wu G, Guo X, Xia Z, You G, Hong Z, Huang K. Prognostic nomogram for 30-day mortality of deep vein thrombosis patients in intensive care unit. BMC Cardiovasc Disord 2021; 21:11. [PMID: 33407152 PMCID: PMC7788873 DOI: 10.1186/s12872-020-01823-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 12/14/2020] [Indexed: 12/29/2022] Open
Abstract
Background We aimed to use the Medical Information Mart for Intensive Care III database to build a nomogram to identify 30-day mortality risk of deep vein thrombosis (DVT) patients in intensive care unit (ICU). Methods Stepwise logistic regression and logistic regression with least absolute shrinkage and selection operator (LASSO) were used to fit two prediction models. Bootstrap method was used to perform internal validation. Results We obtained baseline data of 535 DVT patients, 91 (17%) of whom died within 30 days. The discriminations of two new models were better than traditional scores. Compared with simplified acute physiology score II (SAPSII), the predictive abilities of two new models were improved (Net reclassification improvement [NRI] > 0; Integrated discrimination improvement [IDI] > 0; P < 0.05). The Brier scores of two new models in training set were 0.091 and 0.108. After internal validation, corrected area under the curves for two models were 0.850 and 0.830, while corrected Brier scores were 0.108 and 0.114. The more concise model was chosen to make the nomogram. Conclusions The nomogram developed by logistic regression with LASSO model can provide an accurate prognosis for DVT patients in ICU.
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Affiliation(s)
- Runnan Shen
- Zhongshan School of Medicine, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Ming Gao
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 33, Yingfeng Road, Haizhu District, Guangzhou, 510000, Guangdong Province, China.,Zhongshan School of Medicine, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Yangu Tao
- Department of Traditional Chinese Medicine, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 33, Yingfeng Road, Haizhu District, Guangzhou, 510000, Guangdong Province, China.,Zhongshan School of Medicine, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Qinchang Chen
- The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China.,Zhongshan School of Medicine, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Guitao Wu
- Zhongshan School of Medicine, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Xushun Guo
- Zhongshan School of Medicine, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Zuqi Xia
- Zhongshan School of Medicine, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Guochang You
- Zhongshan School of Medicine, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Zilin Hong
- Zhongshan School of Medicine, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Kai Huang
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 33, Yingfeng Road, Haizhu District, Guangzhou, 510000, Guangdong Province, China. .,Zhongshan School of Medicine, Sun Yat-Sen University, No. 58, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China.
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11
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Gilyarevsky SR, Bendeliani NG, Golshmid MV, Zaharova GY, Kuzmina IM, Sinitcina II. [Evidence-Based Information Which Could Influence Arterial Hypertension Treatment Approach after Publication of SPRINT Trial Results]. ACTA ACUST UNITED AC 2020; 60:130-140. [PMID: 33164724 DOI: 10.18087/cardio.2020.8.n1177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/30/2020] [Indexed: 11/18/2022]
Abstract
The article discusses results of secondary analysis of the data obtained in the SPRINT study and published in recent years. Unresolved issues in the tactics of managing patients with arterial hypertension are discussed. One of such issues is choosing an optimum level of blood pressure (BP) for a subgroup of patients with certain characteristics, including elderly and senile patients, patients with chronic kidney disease, and patients with arterial hypertension who continue smoking. The article discusses calculation of a threshold of risk for complications of cardiovascular diseases, at which a maximum advantage of intensified regimens of antihypertensive therapy could be achieved. In addition, the article addresses approaches to selection of antihypertensive drugs in the current conditions. The authors discussed the role of candesartan in the treatment of arterial hypertension, a sartan most studied in a broad range of patients. The issue of a rapid increase in BP without a damage to target organs is addressed; evidence for the role of captopril in such clinical situation is provided.
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Affiliation(s)
- S R Gilyarevsky
- Medical Academy of Continuing Education Russian Medical Academy of Postgraduate Education, Moscow
| | - N G Bendeliani
- A.N. Bakoulev Scientific Center for Cardiovascular Surgery, Moscow
| | - M V Golshmid
- Medical Academy of Continuing Education Russian Medical Academy of Postgraduate Education, Moscow
| | - G Yu Zaharova
- Medical Academy of Continuing Education Russian Medical Academy of Postgraduate Education, Moscow
| | - I M Kuzmina
- N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow
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12
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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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13
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Oliveros E, Patel H, Kyung S, Fugar S, Goldberg A, Madan N, Williams KA. Hypertension in older adults: Assessment, management, and challenges. Clin Cardiol 2020; 43:99-107. [PMID: 31825114 PMCID: PMC7021657 DOI: 10.1002/clc.23303] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/01/2019] [Accepted: 11/08/2019] [Indexed: 12/12/2022] Open
Abstract
Hypertension in older adults is related to adverse cardiovascular outcomes, such as heart failure, stroke, myocardial infarction, and death. The global burden of hypertension is increasing due to an aging population and increasing prevalence of obesity, and is estimated to affect one third of the world's population by 2025. Adverse outcomes in older adults are compounded by mechanical hemodynamic changes, arterial stiffness, neurohormonal and autonomic dysregulation, and declining renal function. This review highlights the current evidence and summarizes recent guidelines on hypertension, pertaining to older adults. Management strategies for hypertension in older adults must consider the degree of frailty, increasingly complex medical comorbidities, and psycho-social factors, and must therefore be individualized. Non-pharmacological lifestyle interventions should be encouraged to mitigate the risk of developing hypertension, and as an adjunctive therapy to reduce the need for medications. Pharmacological therapy with diuretics, renin-angiotensin system blockers, and calcium channel blockers have all shown benefit on cardiovascular outcomes in older patients. Given the economic and public health burden of hypertension in the United States and globally, it is critical to address lifestyle modifications in younger generations to prevent hypertension with age.
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Affiliation(s)
- Estefania Oliveros
- Department of Internal Medicine, Division of CardiologyRush University Medical Center
| | - Hena Patel
- Department of Internal Medicine, Division of CardiologyRush University Medical Center
| | - Stella Kyung
- Department of Internal Medicine, Division of CardiologyRush University Medical Center
| | - Setri Fugar
- Department of Internal Medicine, Division of CardiologyRush University Medical Center
| | - Alan Goldberg
- Department of Internal Medicine, Division of CardiologyRush University Medical Center
| | - Nidhi Madan
- Department of Internal Medicine, Division of CardiologyRush University Medical Center
| | - Kim A. Williams
- Department of Internal Medicine, Division of CardiologyRush University Medical Center
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14
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Márquez DF, Ruiz-Hurtado G, Segura J, Ruilope L. Microalbuminuria and cardiorenal risk: old and new evidence in different populations. F1000Res 2019; 8. [PMID: 31583081 PMCID: PMC6758838 DOI: 10.12688/f1000research.17212.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2019] [Indexed: 01/13/2023] Open
Abstract
Since the association of microalbuminuria (MAU) with cardiovascular (CV) risk was described, a huge number of reports have emerged. MAU is a specific integrated marker of CV risk and targets organ damage in patients with hypertension, chronic kidney disease (CKD), and diabetes and its recognition is important for identifying patients at a high or very high global CV risk. The gold standard for diagnosis is albumin measured in 24-hour urine collection (normal values of less than 30 mg/day, MAU of 30 to 300 mg/day, macroalbuminuria of more than 300 mg/day) or, more practically, the determination of urinary albumin-to-creatinine ratio in a urine morning sample (30 to 300 mg/g). MAU screening is mandatory in individuals at risk of developing or presenting elevated global CV risk. Evidence has shown that intensive treatment could turn MAU into normoalbuminuria. Intensive treatment with the administration of an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, in combination with other anti-hypertensive drugs and drugs covering other aspects of CV risk, such as mineralocorticoid receptor antagonists, new anti-diabetic drugs, and statins, can diminish the risk accompanying albuminuria in hypertensive patients with or without CKD and diabetes.
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Affiliation(s)
- Diego Francisco Márquez
- Unidad de Hipertensión Arterial-Servicio de Clínica Médica, Hospital San Bernardo, Salta, Argentina
| | - Gema Ruiz-Hurtado
- Instituto de Investigación Imas12 and Unidad de Hipertensión, Hospital 12 de Octubre, Madrid, Spain
| | - Julian Segura
- Instituto de Investigación Imas12 and Unidad de Hipertensión, Hospital 12 de Octubre, Madrid, Spain
| | - Luis Ruilope
- Instituto de Investigación Imas12 and Unidad de Hipertensión, Hospital 12 de Octubre, Madrid, Spain.,Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma, Madrid, Spain.,Escuela de Estudios Postdoctorales and Investigación, Universidad de Europa de Madrid, Madrid, Spain
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15
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Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 138:e484-e594. [PMID: 30354654 DOI: 10.1161/cir.0000000000000596] [Citation(s) in RCA: 210] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul K Whelton
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Robert M Carey
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Wilbert S Aronow
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Donald E Casey
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Karen J Collins
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Cheryl Dennison Himmelfarb
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sondra M DePalma
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Samuel Gidding
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Kenneth A Jamerson
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Daniel W Jones
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Eric J MacLaughlin
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Paul Muntner
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Bruce Ovbiagele
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sidney C Smith
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Crystal C Spencer
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Randall S Stafford
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sandra J Taler
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Randal J Thomas
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Kim A Williams
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Jeff D Williamson
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Jackson T Wright
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
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16
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Cao Z, Wang R, Cheng Y, Yang H, Li S, Sun L, Xu W, Wang Y. Adherence to a healthy lifestyle counteracts the negative effects of risk factors on all-cause mortality in the oldest-old. Aging (Albany NY) 2019; 11:7605-7619. [PMID: 31525731 PMCID: PMC6781993 DOI: 10.18632/aging.102274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/05/2019] [Indexed: 12/18/2022]
Abstract
In the study, we examined the extent to which the harmful effects of risk factors on all-cause mortality can be counteracted by healthy lifestyle practices in the oldest-old (80 years of age and older). A total of 17,660 oldest-old from China were followed up for up to 10 years. The data were analyzed using the Cox proportional hazard model with adjustment for potential confounders. We found that having a rural residence, not being married, having lower economic status, physical disability, impaired cognitive function, or comorbidity were all associated with an elevated risk of mortality. Using these factors, we computed a weighted "risk score." Because never smoking, never drinking, doing physical exercise, having an ideal diet, and a normal weight were independently associated with lower mortality, we also combined them to compute a weighted "protection score." Both scores were divided into lowest, middle, and highest groups using their tertiles. In joint effect analyses, participants with the combined highest-risk score and lowest-protection score profile had a nearly threefold higher joint death risk. These analyses show that adherence to a healthy lifestyle counteracts the negative effect of risk factors on all-cause mortality in the oldest-old by more than 20%.
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Affiliation(s)
- Zhi Cao
- School of Public Health, Tianjin Medical University, Tianjin 300070, P.R. China
| | - Rui Wang
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institute and Stockholm University, Stockholm SE-17177, Sweden
| | - Yangyang Cheng
- School of Public Health, Tianjin Medical University, Tianjin 300070, P.R. China
| | - Hongxi Yang
- School of Public Health, Tianjin Medical University, Tianjin 300070, P.R. China.,Department of Biostatistics, School of Public Health, Yale University, New Haven, CT 06520, USA
| | - Shu Li
- School of Public Health, Tianjin Medical University, Tianjin 300070, P.R. China
| | - Li Sun
- School of Public Health, Tianjin Medical University, Tianjin 300070, P.R. China
| | - Weili Xu
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institute and Stockholm University, Stockholm SE-17177, Sweden
| | - Yaogang Wang
- School of Public Health, Tianjin Medical University, Tianjin 300070, P.R. China
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17
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Masoli JAH, Delgado J, Bowman K, Strain WD, Henley W, Melzer D. Association of blood pressure with clinical outcomes in older adults with chronic kidney disease. Age Ageing 2019; 48:380-387. [PMID: 30824915 PMCID: PMC6504072 DOI: 10.1093/ageing/afz006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 10/30/2018] [Accepted: 01/24/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND in chronic kidney disease (CKD), hypertension is associated with poor outcomes at ages <70 years. At older ages, this association is unclear. We tested 10-year mortality and cardiovascular outcomes by clinical systolic blood pressure (SBP) in older CKD Stages 3 and 4 patients without diabetes or proteinuria. METHODS retrospective cohort in population representative primary care electronic medical records linked to hospital data from the UK. CKD staged by CKD-EPI equation (≥2 creatinine measurements ≥90 days apart). SBPs were 3-year medians before baseline, with mean follow-up 5.7 years. Cox competing models accounted for mortality. RESULTS about 158,713 subjects with CKD3 and 6,611 with CKD4 met inclusion criteria. Mortality increased with increasing CKD stage in all subjects aged >60. In the 70 plus group with SBPs 140-169 mmHg, there was no increase in mortality, versus SBP 130-139. Similarly, SBPs 140-169 mmHg were not associated with increased incident heart failure, stroke or myocardial infarctions. SBPs <120 mmHg were associated with increased mortality and cardiovascular risk. At ages 60-69, there was increased mortality at SBP <120 and SBP >150 mmHg.Results were little altered after excluding those with declining SBPs during 5 years before baseline, or for longer-term outcomes (5-10 years after baseline). CONCLUSIONS in older primary care patients, CKD3 or 4 was the dominant outcome predictor. SBP 140-169 mmHg having little additional predictive value, <120 mmHg was associated with increased mortality. Prospective studies of representative older adults with CKD are required to establish optimum BP targets.
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Affiliation(s)
- Jane A H Masoli
- Epidemiology and Public Health Group, University of Exeter Medical School, RILD Building, Barrack Road, Exeter, UK
- Department of Healthcare for Older People, Royal Devon and Exeter Hospital, Barrack Road, Exeter, UK
| | - Joao Delgado
- Epidemiology and Public Health Group, University of Exeter Medical School, RILD Building, Barrack Road, Exeter, UK
| | - Kirsty Bowman
- Epidemiology and Public Health Group, University of Exeter Medical School, RILD Building, Barrack Road, Exeter, UK
| | - W David Strain
- Department of Healthcare for Older People, Royal Devon and Exeter Hospital, Barrack Road, Exeter, UK
- Diabetes and Vascular Research, University of Exeter Medical School, Exeter, UK
| | - William Henley
- Medical Statistics, University of Exeter Medical School, Exeter, UK
| | - David Melzer
- Epidemiology and Public Health Group, University of Exeter Medical School, RILD Building, Barrack Road, Exeter, UK
- UConn Center on Aging, University of Connecticut Health Center, 263 Farmington Avenue, Farmington CT, USA
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18
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Hua Q, Fan L, Li J. 2019 Chinese guideline for the management of hypertension in the elderly. J Geriatr Cardiol 2019; 16:67-99. [PMID: 30923539 PMCID: PMC6431598 DOI: 10.11909/j.issn.1671-5411.2019.02.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Qi Hua
- Hypertension Branch of Chinese Geriatrics Society
- National Clinical Research Center of the Geriatric Diseases-Chinese Alliance of Geriatric Cardiovascular Disease
| | - Li Fan
- Hypertension Branch of Chinese Geriatrics Society
- National Clinical Research Center of the Geriatric Diseases-Chinese Alliance of Geriatric Cardiovascular Disease
| | - Jing Li
- Hypertension Branch of Chinese Geriatrics Society
- National Clinical Research Center of the Geriatric Diseases-Chinese Alliance of Geriatric Cardiovascular Disease
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19
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Hashemi A, Nourbakhsh S, Asgari S, Mirbolouk M, Azizi F, Hadaegh F. Blood pressure components and incident cardiovascular disease and mortality events among Iranian adults with chronic kidney disease during over a decade long follow-up: a prospective cohort study. J Transl Med 2018; 16:230. [PMID: 30111315 PMCID: PMC6094925 DOI: 10.1186/s12967-018-1603-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 08/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background To explore the association between systolic and diastolic blood pressure (SBP and DBP respectively) and pulse pressure (PP) with cardiovascular disease (CVD) and mortality events among Iranian patients with prevalent CKD. Methods Patients [n = 1448, mean age: 60.9 (9.9) years] defined as those with estimated glomerular filtration rate < 60 ml/min/1.73 m2, were followed from 31 January 1999 to 20 March 2014. Multivariable Cox proportional hazard models were applied to examine the associations between different components of BP with outcomes. Results During a median follow-up of 13.9 years, 305 all-cause mortality and 317 (100 fatal) CVD events (among those free from CVD, n = 1232) occurred. For CVD and CV-mortality, SBP and PP showed a linear relationship, while a U-shaped relationship for DBP was observed with all outcomes. Considering 120 ≤ SBP < 130 as reference, SBP ≥ 140 mmHg was associated with the highest hazard ratio (HR) for CVD [1.68 (1.2–2.34)], all-cause [1.72 (1.19–2.48)], and CV-mortality events [2.21 (1.16–4.22)]. Regarding DBP, compared with 80 ≤ DBP < 85 as reference, the level of ≥ 85 mmHg increased risk of CVD and all-cause mortality events; furthermore, DBP < 80 mmHg was associated with significant HR for CVD events [1.55 (1.08–2.24)], all-cause [1.68 (1.13–2.5)] and CV-mortality events [3.0 (1.17–7.7)]. Considering PP, the highest HR was seen in participants in the 4th quartile for all outcomes of interest; HRs for CVD events [1.92 (1.33–2.78)], all-cause [1.71 (1.11–2.63)] and CV-mortality events [2.22 (1.06–4.64)]. Conclusions Among patients with CKD, the lowest risk of all-cause and CV-mortality as well as incident CVD was observed in those with SBP < 140, 80 ≤ DBP < 85 and PP < 64 mmHg.
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Affiliation(s)
- Ashkan Hashemi
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Parvaneh Street, Velenjak, P.O. Box: 19395-4763, Tehran, Iran
| | - Sormeh Nourbakhsh
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Parvaneh Street, Velenjak, P.O. Box: 19395-4763, Tehran, Iran
| | - Samaneh Asgari
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Parvaneh Street, Velenjak, P.O. Box: 19395-4763, Tehran, Iran
| | - Mohammadhassan Mirbolouk
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Baltimore, USA
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Hadaegh
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Parvaneh Street, Velenjak, P.O. Box: 19395-4763, Tehran, Iran.
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20
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Walther CP, Chandra A, Navaneethan SD. Blood pressure parameters and morbid and mortal outcomes in nondialysis-dependent chronic kidney disease. Curr Opin Nephrol Hypertens 2018; 27:16-22. [PMID: 29045334 DOI: 10.1097/mnh.0000000000000375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Observational and interventional studies provide conflicting evidence regarding optimal blood pressure (BP) control in persons with chronic kidney disease (CKD). Recent publications provide additional information to inform therapeutic decision-making. RECENT FINDINGS Targeting SBP to less than 120 mmHg, versus less than 140 mmHg, decreased cardiovascular events and all-cause mortality in persons with nondiabetic CKD. A meta-analysis of trials testing blood pressure management among nondialysis-dependent CKD patients (15 924 total patients) found more intensive therapies generally reduced mortality in all subgroups. Observational studies demonstrate that low SBP is associated with higher mortality in CKD. A recent report suggests that this is because of death from cardiovascular and noncardiovascular and nonmalignant causes, whereas higher BP is associated with death from cardiovascular causes. The shape of association between BP and cardiovascular and noncardiovascular events also appears to vary depending on baseline risk factors. Furthermore, BP measurement methodology may differ importantly between observational and interventional studies. SUMMARY We review and summarize observational and interventional literature relating BP parameters to key clinical outcomes in persons with CKD. Apart from the inherent differences between these study designs, the disparate findings from trials and observational studies may be because of differences in patient characteristics and BP measurement techniques.
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Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine
| | | | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine.,Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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21
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Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018. [DOI: 10.1161/hyp.0000000000000065 10.1016/j.jacc.2017.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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22
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Antihypertensive therapy in nondiabetic chronic kidney disease: a review and update. ACTA ACUST UNITED AC 2018; 12:154-181. [PMID: 29396103 DOI: 10.1016/j.jash.2018.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/02/2018] [Accepted: 01/12/2018] [Indexed: 01/06/2023]
Abstract
Hypertension is an important contributor to progression of nondiabetic chronic kidney disease (CKD). Compelling observational evidence indicates that the divergence of blood pressure (BP) away from an ideal range in either direction is associated with a progressive rise in the risk of mortality and cardiovascular and renal disease progression. To date, various clinical trials and meta-analyses examining strict versus less intensive BP control in nondiabetic CKD have not conclusively demonstrated a renal advantage of one BP-lowering approach over another, except in certain subgroups such as proteinuric patients where evidence is circumstantial. As recent data have come to light suggesting that intensive BP control yields superior survival and cardiovascular outcomes in patients at high risk for cardiovascular disease, interest in the prospect of whether such benefit extends to individuals with CKD has surged. This review is a comprehensive analysis of antihypertensive literature in nondiabetic renal disease, with a particular emphasis on BP target.
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23
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Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017; 71:e13-e115. [PMID: 29133356 DOI: 10.1161/hyp.0000000000000065] [Citation(s) in RCA: 1547] [Impact Index Per Article: 221.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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24
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Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017; 71:e127-e248. [PMID: 29146535 DOI: 10.1016/j.jacc.2017.11.006] [Citation(s) in RCA: 2991] [Impact Index Per Article: 427.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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Kovesdy CP. Hypertension in chronic kidney disease after the Systolic Blood Pressure Intervention Trial: targets, treatment and current uncertainties. Nephrol Dial Transplant 2017; 32:ii219-ii223. [PMID: 28201651 DOI: 10.1093/ndt/gfw269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 06/12/2016] [Indexed: 11/13/2022] Open
Abstract
Hypertension is the number one cardiovascular (CV) risk factor, and its treatment represents one of the most important interventions in patients at high risk for CV events. Patients with chronic kidney disease (CKD) are at high CV risk, yet as a group they have been excluded from most major blood pressure (BP)-lowering trials examining CV and mortality end points. The paucity of randomized clinical trial evidence for BP lowering in CKD patients is compounded by the fact that the association between BP levels and clinical outcomes in patients with CKD suggests the presence of a J-curve, which makes extrapolations from general population studies especially difficult. The recent completion of the Systolic Blood Pressure Intervention Trial (SPRINT), which enrolled a large number of patients with mild to moderate CKD, has raised hope for much-needed clarity about the ideal systolic BP target in this patient population. This review discusses the epidemiology of hypertension in CKD and the pathophysiologic underpinnings of the distinct associations between BP levels and clinical outcomes in patients with CKD, and it examines the applicability of the SPRINT results to the general CKD population.
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Affiliation(s)
- Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
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26
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Qureshi S, Lorch R, Navaneethan SD. Blood Pressure Parameters and their Associations with Death in Patients with Chronic Kidney Disease. Curr Hypertens Rep 2017; 19:92. [PMID: 29046987 DOI: 10.1007/s11906-017-0790-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Optimal blood pressure (BP) parameters among patients with chronic kidney disease (CKD) have been a matter of debate. This review critically evaluates recent literature to better define the associations of BP parameters and death among individuals with non-dialysis-dependent CKD. RECENT FINDINGS Observational studies report a "U- or J-shaped" association between BP and all-cause mortality in CKD and caution-intensive BP lowering in the elderly. Causes of death have been evaluated in a recent report noting higher cardiovascular and non-cardiovascular/non-malignant-related mortality among CKD population with SBP < 110 and > 150 mmHg. Very few randomized control trials evaluated the impact of different BP targets on patient-centered outcomes in those with CKD. Recently published SPRINT trial results suggest that intensive SBP control (<120 mm Hg) reduces cardiovascular events and all-cause death among non-diabetic patients with and without CKD. Clinical trial evidence supports lower BP target in those with mild to moderate non-diabetic CKD. However, clinical trials are warranted to further determine the beneficial effects of intensive blood pressure control in diabetic CKD population. In elderly population with CKD, BP targets might need to be individualized based on their comorbidities, life expectancy, and other factors.
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Affiliation(s)
- Samaya Qureshi
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Robert Lorch
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
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27
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Gosmanova EO, Kovesdy CP. Blood Pressure Targets in CKD: Lessons Learned from SPRINT and Previous Observational Studies. Curr Cardiol Rep 2017; 18:88. [PMID: 27448402 DOI: 10.1007/s11886-016-0769-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hypertension management is one of the most common clinical tasks in the care of patients with chronic kidney disease (CKD). Elevated blood pressure (BP) is associated with greater risk of all-cause mortality, cardiovascular (CV) disease, and CKD progression in this population. However, it is still debated, to what target(s) BP should be lowered in patients with signs of kidney damage. The Systolic Blood Pressure Intervention Trial (SPRINT) provided new and important information about the effects of lowering systolic BP to a target of <120 mmHg, which is lower than the levels currently recommended by the most guidelines (<140/90 mmHg). The SPRINT results were not only exciting but also surprising for many clinicians because evidence from well-conducted observational studies in CKD patient showed increased mortality in patients with CKD whose office systolic BP levels were <120 mmHg, as compared with systolic BP in 120-139 mmHg range. In the present review, we will discuss whether a systolic BP goal of <120 mmHg that was found to be beneficial for CV and all-cause mortality outcomes in the SPRINT can be generalized to the entire CKD population.
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Affiliation(s)
- Elvira O Gosmanova
- Nephrology Division, Department of Medicine, Albany Medical College, Albany, NY, USA.,Nephrology Section, Stratton VA Medical Center, Albany, NY, USA
| | - Csaba P Kovesdy
- Nephrology Division, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA. .,Nephrology Section, Memphis VA Medical Center, 1030 Jefferson Ave., Memphis, TN, 38104, USA.
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28
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Himeno T, Okuno T, Watanabe K, Nakajima K, Iritani O, Yano H, Morita T, Igarashi Y, Okuro M, Morimoto S. Range in systolic blood pressure and care-needs certification in long-term care insurance in community-dwelling older patients with chronic kidney disease. J Int Med Res 2017; 46:293-306. [PMID: 28835151 PMCID: PMC6011300 DOI: 10.1177/0300060517721795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective Low systolic blood pressure (SBP) is associated with an increased risk for cardiovascular morbidity/mortality in older patients with chronic kidney disease (CKD). The present study evaluated the association between range in blood pressure and first care-needs certification in the Long-term Care Insurance (LTCI) system or death in community-dwelling older subjects with or without CKD. Methods CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m2 or dipstick proteinuria of + or greater. Our study was conducted in 1078 older subjects aged 65-94 years. Associations were estimated using the Cox proportional hazards model. Results During 5 years of follow-up, 135 first certifications and 53 deaths occurred. Among patients with CKD, moderate SBP (130-159 mmHg) was associated with a significantly lower adjusted risk of subsequent total certification (hazard ratio [HR] = 0.44) and subsequent certification owing to dementia (HR = 0.17) compared with SBP < 130 mmHg. These relationships were not observed in non-CKD subjects. Conclusion Lower SBP of <130 mmHg may predict a higher risk for subsequent first care-needs certification in LTCI, especially for dementia, in community-dwelling patients with CKD.
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Affiliation(s)
- Taroh Himeno
- Department of Geriatric Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Tazuo Okuno
- Department of Geriatric Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Keisuke Watanabe
- Department of Geriatric Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Kumie Nakajima
- Department of Geriatric Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Osamu Iritani
- Department of Geriatric Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Hiroshi Yano
- Department of Geriatric Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Takuro Morita
- Department of Geriatric Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Yuta Igarashi
- Department of Geriatric Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Masashi Okuro
- Department of Geriatric Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Shigeto Morimoto
- Department of Geriatric Medicine, Kanazawa Medical University, Ishikawa, Japan
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29
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Navaneethan SD, Schold JD, Jolly SE, Arrigain S, Blum MF, Winkelmayer WC, Nally JV. Blood pressure parameters are associated with all-cause and cause-specific mortality in chronic kidney disease. Kidney Int 2017; 92:1272-1281. [PMID: 28750929 DOI: 10.1016/j.kint.2017.04.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/13/2017] [Accepted: 04/27/2017] [Indexed: 11/17/2022]
Abstract
Previous observational studies reported J or U-shaped associations between blood pressure parameters and mortality in patients with chronic kidney disease (CKD). Here we examined the associations of different blood pressure levels with various causes of death in a CKD population that included patients with eGFR 15-59 ml/min/1.73 m2 with underlying hypertension receiving at least one antihypertensive agent. We obtained data on date and cause of death from State Department of Health mortality files and classified deaths into three categories: cardiovascular, malignancy-related, and non-cardiovascular/non-malignancy related. Cox models were fitted for overall mortality, and separate competing risk regression models for each major cause of death category, to evaluate their associations with various systolic and diastolic blood pressures. During a median follow-up of 3.9 years, 13,332 of 45,412 patients died. Systolic blood pressures under 100, 100-109, 110-119, and over 150 (vs. 130-139 mm Hg) were associated with higher all-cause and cardiovascular mortality. Systolic blood pressures under 100 mm Hg and 100-109 were associated with higher non-cardiovascular/non-malignancy related mortality. Diastolic blood pressures under 50 and 50-59 (vs. 70-79 mm Hg) were associated with higher all-cause and non-cardiovascular/non-malignancy-related mortality while diastolic blood pressures over 90 mm Hg was associated with higher cardiovascular but lower non-cardiovascular/non-malignancy related mortality. Thus, in a non-dialysis dependent CKD population, systolic blood pressures under 110 and over 150 mm Hg were associated with cardiovascular and non-cardiovascular/non-malignancy related deaths. However, diastolic blood pressure under 60 mm Hg was associated in contrast with all-cause mortality and non-cardiovascular/non-malignancy-related deaths.
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Affiliation(s)
- Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
| | - Jesse D Schold
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stacey E Jolly
- Department of General Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA; Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew F Blum
- Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph V Nally
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA; Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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30
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Textor SC, Schwartz GL. BP Targets in CKD, Mortality, and SPRINT: What Have We Learned? J Am Soc Nephrol 2017; 28:2561-2563. [PMID: 28729287 DOI: 10.1681/asn.2017060652] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Gary L Schwartz
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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31
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Canney M, O'Connell MDL, Sexton DJ, O'Leary N, Kenny RA, Little MA, O'Seaghdha CM. Graded Association Between Kidney Function and Impaired Orthostatic Blood Pressure Stabilization in Older Adults. J Am Heart Assoc 2017; 6:JAHA.117.005661. [PMID: 28473404 PMCID: PMC5524105 DOI: 10.1161/jaha.117.005661] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Impaired orthostatic blood pressure (BP) stabilization is highly prevalent in older adults and is a predictor of end‐organ injury, falls, and mortality. We sought to characterize the relationship between postural BP responses and the kidney. Methods and Results We performed a cross‐sectional analysis of 4204 participants from The Irish Longitudinal Study on Ageing, a national cohort of community‐dwelling adults aged ≥50 years. Beat‐to‐beat systolic and diastolic BP were measured during a 2‐minute active stand test. The primary predictor was cystatin C estimated glomerular filtration rate (eGFR) categorized as follows (mL/min per 1.73 m2): ≥90 (reference, n=1414); 75 to 89 (n=1379); 60 to 74 (n=942); 45 to 59 (n=337); <45 (n=132). We examined the association between eGFR categories and (1) sustained orthostatic hypotension, defined as a BP drop exceeding consensus thresholds (systolic BP drop ≥20 mm Hg±diastolic BP drop ≥10 mm Hg) at each 10‐second interval from 60 to 110 seconds inclusive; (2) pattern of BP stabilization, characterized as the difference from baseline in mean systolic BP/diastolic BP at 10‐second intervals. The mean age of subjects was 61.6 years; 47% of subjects were male, and the median eGFR was 82 mL/min per 1.73 m2. After multivariable adjustment, participants with eGFR <60 mL/min per 1.73 m2 were approximately twice as likely to have sustained orthostatic hypotension (P=0.008 for trend across eGFR categories). We observed a graded association between eGFR categories and impaired orthostatic BP stabilization, particularly within the first minute of standing. Conclusions We report a novel, graded relationship between diminished eGFR and impaired orthostatic BP stabilization. Mapping the postural BP response merits further study in kidney disease as a potential means of identifying those at risk of hypotension‐related events.
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Affiliation(s)
- Mark Canney
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin 2, Ireland .,Trinity Health Kidney Centre, Tallaght Hospital, Dublin 24, Ireland
| | - Matthew D L O'Connell
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin 2, Ireland
| | - Donal J Sexton
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin 2, Ireland.,Trinity Health Kidney Centre, Tallaght Hospital, Dublin 24, Ireland
| | - Neil O'Leary
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin 2, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin 2, Ireland
| | - Mark A Little
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin 24, Ireland
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32
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Svensson MK, Afghahi H, Franzen S, Björk S, Gudbjörnsdottir S, Svensson AM, Eliasson B. Decreased systolic blood pressure is associated with increased risk of all-cause mortality in patients with type 2 diabetes and renal impairment: A nationwide longitudinal observational study of 27,732 patients based on the Swedish National Diabetes Register. Diab Vasc Dis Res 2017; 14:226-235. [PMID: 28467201 DOI: 10.1177/1479164116683637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Previous studies have shown a U-shaped relationship between systolic blood pressure and risk of all-cause of mortality in patients with type 2 diabetes and renal impairment. AIMS To evaluate the associations between time-updated systolic blood pressure and time-updated change in systolic blood pressure during the follow-up period and risk of all-cause mortality in patients with type 2 diabetes and renal impairment. PATIENTS AND METHODS A total of 27,732 patients with type 2 diabetes and renal impairment in the Swedish National Diabetes Register were followed for 4.7 years. Time-dependent Cox models were used to estimate risk of all-cause mortality. Time-updated mean systolic blood pressure is the average of the baseline and the reported post-baseline systolic blood pressures. RESULTS A time-updated systolic blood pressure < 130 mmHg was associated with a higher risk of all-cause mortality in patients both with and without a history of chronic heart failure (hazard ratio: 1.25, 95% confidence interval: 1.13-1.40 and hazard ratio: 1.26, 1.17-1.36, respectively). A time-updated decrease in systolic blood pressure > 10 mmHg between the last two observations was associated with higher risk of all-cause mortality (-10 to -25 mmHg; hazard ratio: 1.24, 95% confidence interval: 1.17-1.32). CONCLUSION Both low systolic blood pressure and a decrease in systolic blood pressure during the follow-up are associated with a higher risk of all-cause mortality in patients with type 2 diabetes and renal impairment.
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Affiliation(s)
- Maria K Svensson
- 1 Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Henri Afghahi
- 2 Department of Nephrology, Skaraborg Hospital, Skövde, Sweden
| | - Stefan Franzen
- 3 Centre of Registers Västra Götaland, Gothenburg, Sweden
| | - Staffan Björk
- 3 Centre of Registers Västra Götaland, Gothenburg, Sweden
| | | | | | - Björn Eliasson
- 4 Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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33
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Guerrot D, Godin M. Cibles de pression artérielle en néphrologie en 2017. Nephrol Ther 2017; 13 Suppl 1:S69-S74. [DOI: 10.1016/j.nephro.2017.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 01/08/2017] [Indexed: 11/25/2022]
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34
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Tyson CC, Coffman TM. In the Wake of Systolic Blood Pressure Intervention Trial: New Targets for Improving Hypertension Management in Chronic Kidney Disease? Nephron Clin Pract 2017; 135:287-290. [PMID: 28161697 DOI: 10.1159/000455130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 12/12/2016] [Indexed: 01/13/2023] Open
Abstract
Systolic Blood Pressure Intervention Trial (SPRINT) was a multicenter randomized controlled trial showing the significant benefit of intensive reduction of blood pressure to a target of 120 mm Hg in individuals with hypertension and elevated cardiovascular risk. Because SPRINT includes the largest cohort of adults with chronic kidney disease (CKD) to be prospectively studied in a hypertension intervention trial, it has particular relevance to the field of nephrology. Here, we review the findings of SPRINT and assess their potential impact on guidelines for treatment of hypertension in patients with CKD. We believe that the data from SPRINT will support a recommendation for lowering blood pressure targets to 120 mm Hg in a substantial segment of adults with CKD.
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Affiliation(s)
- Crystal C Tyson
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Franco Palacios CR, Goyal P, Thompson AM, Deschaine B. Systolic blood pressure values might further risk-stratify the adverse outcomes of LVH in older patients with chronic kidney disease. Clin Hypertens 2016; 22:21. [PMID: 27895935 PMCID: PMC5120495 DOI: 10.1186/s40885-016-0056-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 11/08/2016] [Indexed: 11/10/2022] Open
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Bansal N, McCulloch CE, Lin F, Robinson-Cohen C, Rahman M, Kusek JW, Anderson AH, Xie D, Townsend RR, Lora CM, Wright J, Go AS, Ojo A, Alper A, Lustigova E, Cuevas M, Kallem R, Hsu CY. Different components of blood pressure are associated with increased risk of atherosclerotic cardiovascular disease versus heart failure in advanced chronic kidney disease. Kidney Int 2016; 90:1348-1356. [PMID: 27717485 DOI: 10.1016/j.kint.2016.08.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 07/25/2016] [Accepted: 08/11/2016] [Indexed: 11/24/2022]
Abstract
Blood pressure is a modifiable risk for cardiovascular disease (CVD). Among hemodialysis patients, there is a U-shaped association between blood pressure and risk of death. However, few studies have examined the association between blood pressure and CVD in patients with stage 4 and 5 chronic kidney disease. Here we studied 1795 Chronic Renal Insufficiency Cohort (CRIC) Study participants with estimated glomerular filtration rate <30 ml/min per 1.73 m2 and not on dialysis. The association of systolic (SBP), diastolic (DBP), and pulse pressure with the risk of physician-adjudicated atherosclerotic CVD (stroke, myocardial infarction, or peripheral arterial disease) and heart failure was tested using Cox regression adjusted for demographics, comorbidity and medications. There was a significant association with higher SBP (adjusted hazard ratio 2.04 [95% confidence interval: 1.46-2.84]) for SBP over 140 vs under 120 mmHg, higher DBP (2.52 [1.54-4.11]) for DBP >90 mm Hg versus <80 mm Hg and higher pulse pressure (2.67 [1.82-3.92]) for pulse pressure >68 mm Hg versus <51 mm Hg with atherosclerotic CVD. For heart failure, there was a significant association with higher pulse pressure only (1.42 [1.05-1.92]) for pulse pressure >68 mm Hg versus <51 mmHg, but not for SBP or DBP. Thus, among participants with stage 4 and 5 chronic kidney disease, there was an independent association between higher SBP, DBP, and pulse pressure with the risk of atherosclerotic CVD, whereas only higher pulse pressure was independently associated with a greater risk of heart failure. Further trials are needed to determine whether aggressive reduction of blood pressure decreases the risk of CVD events in patients with stage 4 and 5 chronic kidney disease.
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Affiliation(s)
- Nisha Bansal
- Department of Medicine, University of Washington, Seattle, Washington, USA.
| | - Charles E McCulloch
- Department of Biostatistics and Epidemiology, University of California, San Francisco, San Francisco, California, USA
| | - Feng Lin
- Department of Biostatistics and Epidemiology, University of California, San Francisco, San Francisco, California, USA
| | | | - Mahboob Rahman
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Amanda H Anderson
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dawei Xie
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Claudia M Lora
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jackson Wright
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Division of Research, Oakland, California, USA
| | - Akinlolu Ojo
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Arnold Alper
- Department of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Eva Lustigova
- School of Public Health, Tulane University, New Orleans, Louisiana, USA
| | - Magda Cuevas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Radhakrishna Kallem
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chi-Yuan Hsu
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, Kaiser Permanente Division of Research, Oakland, California, USA
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Franco Palacios CR, Haugen EN, Thompson AM, Rasmussen RW, Goracke N, Goyal P. Clinical outcomes with a systolic blood pressure lower than 120 mmHg in older patients with high disease burden. Ren Fail 2016; 38:1364-1369. [PMID: 27607547 DOI: 10.1080/0886022x.2016.1227924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND The target blood pressure in older patients is controversial. Recent studies provided clinical evidence supporting a target systolic blood pressure <120 mmHg in patients >50 years at high risk of cardiovascular events. METHODS Retrospective study of 380 consecutive patients ≥60 years with stages 1-5 pre-dialysis chronic kidney disease seen between January 2013 and November 2015. The outcomes of a systolic blood pressure <120 mmHg in older patients with chronic kidney disease and multiple comorbidities were analyzed. RESULTS Sixty-eight patients had a systolic blood pressure <120 mmHg, 312 patients had a systolic blood pressure ≥120 mmHg. Forty-three patients died during the follow up (11.3%). Patients with a systolic blood pressure <120 mmHg had a higher risk of death: 21 (30.9%) vs 22 (7%). Primary cause of death: Cardiovascular: 11 (25.6%), infectious 9 (20.9%), cancer 5 (11.6%), renal failure 6 (13.9%), COPD/pulmonary fibrosis 2 (4.6%), end stage liver disease 3 (6.9%), traumatic brain injury 1 (2.3%), gastrointestinal hemorrhage 4 (9.3%), complications of diabetes 1 (2.3%), unknown 1 (2.3%). After adjusting for confounding factors, a systolic blood pressure <120 mmHg remained associated with increased mortality. There was a trend to more cardiovascular outcomes in those with a lower blood pressure. CONCLUSIONS A systolic blood pressure below 120 mmHg in older patients with high disease burden was associated with adverse outcomes. Individualization of blood pressure therapy to each specific patient is warranted.
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Affiliation(s)
- Carlos R Franco Palacios
- a Nephrology Department , Affiliated Community Medical Centers, Rice Memorial Hospital , Willmar , MN , USA
| | - Eric N Haugen
- a Nephrology Department , Affiliated Community Medical Centers, Rice Memorial Hospital , Willmar , MN , USA
| | | | - Richard W Rasmussen
- a Nephrology Department , Affiliated Community Medical Centers, Rice Memorial Hospital , Willmar , MN , USA
| | - Nathan Goracke
- b Pharmacy Department , Rice Memorial Hospital , Willmar , MN , USA
| | - Pankaj Goyal
- c Hospital Medicine Department , Affiliated Community Medical Centers, Rice Memorial Hospital , Willmar , MN , USA
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Weiss JW. The Continued Quest for Optimal BP Targets in Older Adults with Kidney Disease. Clin J Am Soc Nephrol 2016; 11:753-755. [PMID: 27103622 PMCID: PMC4858475 DOI: 10.2215/cjn.03100316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Jessica W Weiss
- Division of Nephrology and Hypertension, Department of Internal Medicine, Oregon Health and Science University, Portland, Oregon
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Kovesdy CP, Alrifai A, Gosmanova EO, Lu JL, Canada RB, Wall BM, Hung AM, Molnar MZ, Kalantar-Zadeh K. Age and Outcomes Associated with BP in Patients with Incident CKD. Clin J Am Soc Nephrol 2016; 11:821-831. [PMID: 27103623 PMCID: PMC4858482 DOI: 10.2215/cjn.08660815] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 02/01/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Hypertension is the most important treatable risk factor for cardiovascular outcomes. Many patients with CKD are elderly, but the ideal BP in these individuals is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS From among 339,887 patients with incident eGFR<60 ml/min per 1.73 m(2), we examined associations of systolic BP (SBP) and diastolic BP (DBP) with all-cause mortality, incident coronary heart disease (CHD), ischemic strokes, and ESRD from the time of developing CKD until the end of follow-up (July 26, 2013, for mortality, CHD, and stroke, and December 31, 2011, for ESRD) in multivariable-adjusted survival models categorized by patients' age. RESULTS Of the total cohort, 300,424 (88%) had complete data for multivariable analysis. Both SBP and DBP showed a U-shaped association with mortality. SBP displayed a linear association with CHD, stroke, and ESRD, whereas DBP showed no consistent association with either. SBP>140 mmHg was associated with higher incidence of all examined outcomes, but with an incremental attenuation of the observed risk in older compared with younger patients (P<0.05 for interaction) The adjusted hazard ratios and 95% confidence intervals associated with SBP≥170 mmHg (compared with 130-139 mmHg) in patients <50, 50-59, 60-69, 70-79, and ≥80 years were 1.95 (1.34 to 2.84), 2.01 (1.75 to 2.30), 1.68 (1.49 to 1.89), 1.39 (1.25 to 1.54), and 1.30 (1.17 to 1.44), respectively. The risk of incident CHD, stroke, and ESRD was incrementally higher with higher SBP in patients aged <80 years but showed no consistent association in those aged ≥80 years (P<0.05 for interaction for all outcomes). CONCLUSIONS In veterans with incident CKD, SBP showed different associations in older versus younger patients. The association of higher SBP with adverse outcomes was present but markedly reduced in older individuals, especially in those aged ≥80 years. Elevated DBP showed no consistent association with vascular outcomes in patients with incident CKD.
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Affiliation(s)
- Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Ahmed Alrifai
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Elvira O. Gosmanova
- Nehphrology Section, Straton Veterans Affairs Medical Center, Albany, New York
- Department of Medicine, Albany Medical College, Albany, New York
| | - Jun Ling Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Robert B. Canada
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Barry M. Wall
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Adriana M. Hung
- Nephrology Section, Nashville Veterans Affairs Medical Center, Nashville, Tennessee
- Division of Nephrology, Vanderbilt University, Nashville, Tennessee; and
| | - Miklos Z. Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California
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Norris KC, Nicholas SB. Strategies for Controlling Blood Pressure and Reducing Cardiovascular Disease Risk in Patients with Chronic Kidney Disease. Ethn Dis 2015; 25:515-20. [PMID: 26675050 PMCID: PMC4671428 DOI: 10.18865/ed.25.4.515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Patients with chronic kidney disease (CKD) suffer from an increased prevalence of cardiovascular disease (CVD) risk factors, and a high rate of premature CV morbidity and mortality. The confluence of CV risk factors, in the context of cardio-metabolic perturbations that vary as renal function declines, complicates strategies for the care of patients with CKD. Understanding the existing evidence for effective CVD treatment strategies can help providers better care for these patients, navigate the complex treatment guidelines, which often differ across major organizations, and minimize the conflicting recommendations that new studies may pose. A pragmatic approach is to target a BP <140/90 mm Hg, which frequently requires more than two or three antihypertensive agents. Most guidelines recommend a combination of diuretic and angiotensin converting enzyme inhibitor or angiotensin receptor blockers, along with a dihydropyridine calcium channel blocker, beta blocker or other agent based on co-existing medical conditions. Consideration for a lower BP goal and/or other therapeutic interventions should be based on the etiology of CKD, stage of CKD, and/or presence of proteinuria. Finally, most patients with CKD, not on dialysis, would benefit from treatment with statins and non-pharmacologic lifestyle interventions should be promoted for all patients with CKD.
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Affiliation(s)
- Keith C. Norris
- 1. Division of General Internal Medicine and Division of Nephrology; Department of Medicine; David Geffen School of Medicine; University of California, Los Angeles
| | - Susanne B. Nicholas
- 2. Division of Nephrology and Division of Endocrinology, Diabetes and Hypertension; Department of Medicine; David Geffen School of Medicine; University of California, Los Angeles
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Navaneethan SD, Whaley-Connell A. BP Targets in Older Adults with CKD: Additional Evidence, but Uncertainty Continues. Clin J Am Soc Nephrol 2015; 10:1501-3. [PMID: 26276139 PMCID: PMC4559514 DOI: 10.2215/cjn.07870715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sankar D Navaneethan
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas; and
| | - Adam Whaley-Connell
- Research Service, Harry S. Truman Memorial Veterans Hospital, Department of Medicine, Divisions of Nephrology and Hypertension and Division of Endocrinology and Metabolism, University of Missouri-Columbia School of Medicine, Columbia, Missouri
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