Blood pressure control in patients with chronic kidney disease

Blood pressure control in diabetic kidney disease: a post-hoc analysis of the FANTASTIC trial

BACKGROUND

The target blood pressure (BP) value is unclear for diabetic kidney disease (DKD). Therefore, we aimed to evaluate the effect of strict BP control or 'on treatment' BP on clinical outcomes in patients with DKD.

METHODS

A post-hoc analysis of the prespecified secondary outcomes of the FimAsartaN proTeinuriA SusTaIned reduCtion in comparison with losartan in diabetic chronic kidney disease (FANTASTIC) trial, a randomized multicenter double-blind phase III trial. Eligible patients were aged ≥ 19 years with DKD. We assigned 341 participants with DKD to BP control strategy (standard-systolic BP [SBP] < 140 mmHg versus strict-SBP < 130 mmHg). The outcome was the occurrence of cardiovascular events and renal events. Separate analyses were performed to compared the risk of outcome according to achieved average BP levels.

RESULTS

A total of 341 participants were included in the analysis. Over a median follow-up of 2.8 years, cardiovascular/renal events were observed in 25 (7.3%) participants. Mean (SD) SBPs in the standard and strict BP control group were 140.2 (11.6) and 140.2 (11.9) mmHg, respectively. The strict BP control group did not show significantly reduced risk of cardiovascular/renal events (HR 1.32; 95% CI 0.60-2.92]). In the post-hoc analyses using achieved BP, achieved average SBP of 130-139 mmHg resulted in reduced risk of cardiovascular/renal events (HR 0.15; 95% CI 0.03-0.67) compared to achieved average SBP ≥ 140 mmHg, whereas further reduction in achieved average SBP < 130 mmHg did not impart additional benefits.

CONCLUSION

In patients with DKD, targeting a SBP of less than 130 mmHg, as compared with less than 140 mmHg, did not reduce the rate of a composite of cardiovascular and renal events. Achieved SBP of 130-139 mmHg was associated with a decreased risk for the primary outcome in patients with DKD.

TRIAL REGISTRATION

ClinicalTirals.gov Identifier: NCT02620306, registered December 3, 2015. ( https://clinicaltrials.gov/study/NCT02620306 ).

Prognostic factors affecting long-term outcomes in patients with concurrent IgA nephropathy and membranous nephropathy

Background

The incidence of concurrent immunoglobulin A nephropathy and membranous nephropathy (cIgAN/MN) is low and rarely reported, and the prognosis of patients with cIgAN/MN remains unclear. This study was designed to compare the clinical and prognostic characteristics of cIgAN/MN with IgAN and MN and to identify crucial factors influencing the outcomes of patients with cIgAN/MN.

Methods

We included biopsy-proven cIgAN/MN patients between December 2012 and December 2020 at Xijing Hospital. In the same period, propensity score matching was employed to select an equal number of IgAN and MN patients according to the following criteria: age, sex, and follow-up time. The primary endpoint was defined as a composite of eGFR decline ≥30 %, end-stage renal disease, or death. The patient survival rate was examined using Kaplan-Meier survival curves. Univariate and multivariate Cox regression analysis models were utilized to identify the risk factors affecting renal prognosis.

Results

A total of 135 patients were finally included in this study and 35 (25.9 %) reached the primary endpoint. The median follow-up time of cIgAN/MN was 45.9 (24.0, 72.0) months. Compared to the IgAN group, the cIgAN/MN group exhibited a lower cumulative incidence rate of composite renal endpoints (P = 0.044), while no significant difference was found between MN and cIgAN/MN patients (P = 0.211). Univariate Cox analysis revealed that mean arterial pressure, serum potassium, blood urea nitrogen, serum IgA, segmental glomerulosclerosis (S1), and MN staging were associated with an increased risk of renal composite endpoints. The multivariate Cox regression analysis of clinical variables plus histological lesion scoring demonstrated that potassium (HR = 14.350, 95 % CI 2.637-78.090, P = 0.002), serum IgA (HR = 1.870, 95 % CI 1.109-3.153, P = 0.019), and S1 (HR = 11.965, 95 % CI 2.166-66.105, P = 0.004) were independent risk factors influencing renal outcomes in cIgAN/MN patients.

Conclusion

The prognosis of cIgAN/MN patients may exhibit an intermediate pattern between IgAN and MN, leaning towards being more similar to MN in certain aspects. Within the cIgAN/MN cohort, potassium, and serum IgA may be more predictive of rapid progression of renal endpoints, and S1 may indicate a more aggressive disease course.

Prevalence of and factors associated with uncontrolled hypertension among patients with early chronic kidney disease attending tertiary hospitals in Dodoma, Tanzania: a cross-sectional study

OBJECTIVE

To determine the prevalence of uncontrolled hypertension and its associated factors among patients with early chronic kidney disease (CKD) attending medical outpatient clinics at tertiary hospitals in Dodoma, Tanzania.

DESIGN

Cross-sectional study.

SETTING

Two tertiary hospitals in Dodoma, Tanzania.

PARTICIPANTS

The participants in this study were adult patients (≥18 years) with early CKD stages (1, 2 and 3) who were attending nephrology and medical outpatient clinics from November 2020 to March 2021. Patients who had been attending the clinic for at least 3 months, had baseline clinical data on their files, had estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2 and who provided written informed consent were eligible. A total of 352 patients were enrolled, of whom 182 were men and 170 were women.

OUTCOME MEASURE

The dependent variable was uncontrolled hypertension among patients with early CKD, based on blood pressure measurements.

RESULTS

The prevalence of hypertension was 58.5% (206 of 352) and the prevalence of uncontrolled hypertension was 58.3% (120 of 206). Among patients with uncontrolled hypertension, 88.3% (106 of 120) had CKD stage 3, 80.2% (96 of 120) reported non-adherence to antihypertensives, 76.7% (92 of 120) were overweight or obese, 72.5% (87 of 120) reported current alcohol use and 26.7% (32 of 120) had diabetes mellitus. Factors that contributed to higher odds of uncontrolled hypertension were: age ≥50 years (OR=5.17, 95 % CI 2.37 to 13.33, p=0.001), alcohol use (OR=11.21, 95% CI 3.83 to 32.84, p=0.001), non-adherence to antihypertensives (OR=10.19, 95% CI 4.22 to 24.61, p=0.001), overweight/obesity (OR=6.28, 95% CI 2.54 to 15.53, p=0.001) and CKD stage 3 (OR=3.52, 95% CI 1.32 to 9.42, p=0.012).

CONCLUSION

Uncontrolled hypertension was highly prevalent among patients with early CKD in this setting and was associated with age, current alcohol use, non-adherence to antihypertensives, overweight/obesity and declining eGFR.

Hypertension as Cardiovascular Risk Factor in Chronic Kidney Disease

Hypertension is the leading modifiable cause of premature death and hence one of the global targets of World Health Organization for prevention. Hypertension also affects the great majority of patients with chronic kidney disease (CKD). Both hypertension and CKD are intrinsically related, as hypertension is a strong determinant of worse renal and cardiovascular outcomes and renal function decline aggravates hypertension. This bidirectional relationship is well documented by the high prevalence of hypertension across CKD stages and the dual benefits of effective antihypertensive treatments on renal and cardiovascular risk reduction. Achieving an optimal blood pressure (BP) target is mandatory and requires several pharmacological and lifestyle measures. However, it also requires a correct diagnosis based on reliable BP measurements (eg, 24-hour ambulatory BP monitoring, home BP), especially for populations like patients with CKD where reduced or reverse dipping patterns or masked and resistant hypertension are frequent and associated with a poor cardiovascular and renal prognosis. Even after achieving BP targets, which remain debated in CKD, the residual cardiovascular risk remains high. Current antihypertensive options have been enriched with novel agents that enable to lower the existing renal and cardiovascular risks, such as SGLT2 (sodium-glucose cotransporter-2) inhibitors and novel nonsteroidal mineralocorticoid receptor antagonists. Although their beneficial effects may be driven mostly from actions beyond BP control, recent evidence underline potential improvements on abnormal 24-hour BP phenotypes such as nondipping. Other promising novelties are still to come for the management of hypertension in CKD. In the present review, we shall discuss the existing evidence of hypertension as a cardiovascular risk factor in CKD, the importance of identifying hypertension phenotypes among patients with CKD, and the traditional and novel aspects of the management of hypertensives with CKD.

Hypothetical intervention of targeted systolic blood pressure control of < 120 mmHg on renal prognosis for persons with stage 3-4 chronic kidney disease: an application of parametric g-formula using health checkup data in Japan

BACKGROUND

The revised KDIGO guidelines recommend maintaining systolic blood pressure (sBP) < 120 mmHg in patients with chronic kidney disease (CKD), based on cardiovascular and survival benefits. However, the renal benefit of this strategy remains less clear.

METHODS

We used data of routine health checkups in Japan. Persons whose estimated glomerular filtration rate (eGFR) was < 60 mL/min/1.73 m² in 2015 without end-stage disease were followed until 2020. We estimated the 5-year benefit of hypothetical targeted sBP control using parametric g-formula modeling, accounting for both time-fixed and time-varying confounding variables. Four sensitivity analyses, including analysis using a marginal structural model (MSM) and positive control outcome analysis, were also done.

RESULTS

We enrolled 28,972 persons with CKD (median age: 54 years, male: 69%, baseline eGFR [median]: 56 mL/min/1.73m²). As compared with the natural course without a targeted intervention, there was no renoprotective effect of targeted sBP control, with a 5-year difference in eGFR of 0.65 mL/min/1.73 m² (95% confidence interval - 0.42 to 1.65 mL/min/1.73 m²). MSM analysis found a similar result. In contrast, the positive control analysis using the cardiovascular outcome showed that targeted sBP control would reduce the cardiovascular disease incidence by 6.0% over 5 years.

CONCLUSIONS

A targeted sBP control strategy maintaining < 120 mmHg may not yield a renoprotective effect for patients with stage 3-4 CKD, although it was expected to offer a cardiovascular benefit. Future research may be warranted in higher-risk populations, such as elderly people or those with more advanced kidney disease.