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Thomas G, Felts J, Brecklin CS, Chen J, Drawz PE, Lustigova E, Mehta R, Miller ER, Sozio SM, Weir MR, Xie D, Wang X, Rahman M. Apparent Treatment-Resistant Hypertension Assessed by Office and Ambulatory Blood Pressure in Chronic Kidney Disease-A Report from the Chronic Renal Insufficiency Cohort Study. ACTA ACUST UNITED AC 2020; 1:810-818. [PMID: 34308363 DOI: 10.34067/kid.0002072020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Apparent treatment-resistant hypertension is common in patients with CKD. Whether measurement of 24-hour ambulatory BP monitoring is valuable for risk-stratifying patients with resistant hypertension and CKD is unclear. Methods We analyzed data from the Chronic Renal Insufficiency Cohort study, a prospective study of participants (n=1186) with CKD. Office BP was measured using standardized protocols; ambulatory BP was measured using Spacelabs monitors. Apparent treatment-resistant hypertension was defined on the basis of office BP, ambulatory BP monitoring, and use of more than three antihypertensive medications. Outcomes were composite cardiovascular disease, kidney outcomes, and mortality. Groups were compared using Cox regression analyses with a control group of participants without apparent treatment-resistant hypertension. Results Of 475 participants with apparent treatment-resistant hypertension on the basis of office BP, 91.6% had apparent treatment-resistant hypertension confirmed by ambulatory BP monitoring. Unadjusted event rates of composite cardiovascular disease, kidney outcomes, and mortality were higher in participants with ambulatory BP monitoring-defined apparent treatment-resistant hypertension compared with participants without apparent treatment-resistant hypertension. In adjusted analyses, the risks of composite cardiovascular disease (hazard ratio, 1.27; 95% confidence interval [95% CI], 0.59 to 2.7), kidney outcomes (hazard ratio, 1.68; 95% CI, 0.88 to 3.21), and mortality (hazard ratio, 1.27; 95% CI, 0.5 to 3.25) were not statistically significantly higher in participants with ambulatory BP monitoring-defined apparent treatment-resistant hypertension compared with participants without apparent treatment-resistant hypertension. Conclusions In our study population with CKD, most patients with apparent treatment-resistant hypertension defined on the basis of office BP have apparent treatment-resistant hypertension confirmed by ambulatory BP monitoring. Although ABPM-defined apparent treatment-resistant hypertension was not independently associated with clinical outcomes, it identified participants at high risk for adverse clinical outcomes.
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Affiliation(s)
- George Thomas
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - Jesse Felts
- Department of Medicine, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | - Jing Chen
- Department of Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Paul E Drawz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Eva Lustigova
- Kaiser Permanente Medical Group, Pasadena, California
| | - Rupal Mehta
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| | - Edgar R Miller
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Stephen M Sozio
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Dawei Xie
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Xue Wang
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Mahboob Rahman
- Department of Medicine, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
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Thomas G, Xie D, Chen HY, Anderson AH, Appel LJ, Bodana S, Brecklin CS, Drawz P, Flack JM, Miller ER, Steigerwalt SP, Townsend RR, Weir MR, Wright JT, Rahman M. Prevalence and Prognostic Significance of Apparent Treatment Resistant Hypertension in Chronic Kidney Disease: Report From the Chronic Renal Insufficiency Cohort Study. Hypertension 2015; 67:387-96. [PMID: 26711738 DOI: 10.1161/hypertensionaha.115.06487] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/03/2015] [Indexed: 11/16/2022]
Abstract
The association between apparent treatment resistant hypertension (ATRH) and clinical outcomes is not well studied in chronic kidney disease. We analyzed data on 3367 hypertensive participants in the Chronic Renal Insufficiency Cohort (CRIC) to determine prevalence, associations, and clinical outcomes of ATRH in nondialysis chronic kidney disease patients. ATRH was defined as blood pressure ≥140/90 mm Hg on ≥3 antihypertensives, or use of ≥4 antihypertensives with blood pressure at goal at baseline visit. Prevalence of ATRH was 40.4%. Older age, male sex, black race, diabetes mellitus, and higher body mass index were independently associated with higher odds of having ATRH. Participants with ATRH had a higher risk of clinical events than participants without ATRH-composite of myocardial infarction, stroke, peripheral arterial disease, congestive heart failure (CHF), and all-cause mortality (hazard ratio [95% confidence interval], 1.38 [1.22-1.56]); renal events (1.28 [1.11-1.46]); CHF (1.66 [1.38-2.00]); and all-cause mortality (1.24 [1.06-1.45]). The subset of participants with ATRH and blood pressure at goal on ≥4 medications also had higher risk for composite of myocardial infarction, stroke, peripheral arterial disease, CHF, and all-cause mortality (hazard ratio [95% confidence interval], (1.30 [1.12-1.51]) and CHF (1.59 [1.28-1.99]) than those without ATRH. ATRH was associated with significantly higher risk for CHF and renal events only among those with estimated glomerular filtration rate ≥30 mL/min per 1.73 m(2). Our findings show that ATRH is common and associated with high risk of adverse outcomes in a cohort of patients with chronic kidney disease. This underscores the need for early identification and management of patients with ATRH and chronic kidney disease.
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Affiliation(s)
- George Thomas
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Dawei Xie
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Hsiang-Yu Chen
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Amanda H Anderson
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Lawrence J Appel
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Shirisha Bodana
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Carolyn S Brecklin
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Paul Drawz
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - John M Flack
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Edgar R Miller
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Susan P Steigerwalt
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Raymond R Townsend
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Matthew R Weir
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Jackson T Wright
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Mahboob Rahman
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
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