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Assessment of Vascular Function in Patients With Chronic Kidney Disease
Published on: June 16, 2014
Effect of Blood Pressure Control on Long-Term Risk of End-Stage Renal Disease and Death Among Subgroups of Patients
Elaine Ku1,2, Mark J Sarnak3, Robert Toto4
1Division of Nephrology Department of Medicine University of California San Francisco San Francisco, CA.
Insights
Intensive blood pressure control benefits chronic kidney disease patients, particularly those with higher proteinuria, lower kidney function, older age, or obesity. Strict blood pressure management reduces risks of kidney failure and death without increasing harm in any subgroup.
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Clinical Trials
Background:
- Chronic kidney disease (CKD) affects millions globally, necessitating effective management strategies.
- Blood pressure (BP) control is a cornerstone of CKD management, but its impact on specific subgroups requires further elucidation.
- Understanding differential effects of intensive BP control can optimize patient care and outcomes.
Purpose of the Study:
- To investigate the effect of intensive blood pressure (BP) control on kidney and death outcomes in CKD patients.
- To analyze these effects across subgroups defined by baseline proteinuria, glomerular filtration rate (GFR), age, and body mass index (BMI).
- To determine if intensive BP lowering is uniformly beneficial or if specific patient characteristics modify treatment efficacy.
Main Methods:
- Pooled data from 840 MDRD (Modification of Diet in Renal Disease) trial and 1067 AASK (African American Study of Kidney Disease and Hypertension) participants.
- Utilized Cox proportional hazards models to assess the association between intensive BP control and risk of end-stage renal disease (ESRD) or death.
- Examined interaction effects between intensive BP control and baseline proteinuria (≥0.44 vs <0.44 g/g), GFR (≥30 vs <30 mL/min/1.73 m²), age (≥40 vs <40 years), and BMI (≥30 vs <30 kg/m²).
Main Results:
- Intensive BP control was associated with a reduced risk of ESRD in patients with proteinuria ≥0.44 g/g (HR 0.77) and in those aged ≥40 years (HR 0.82).
- Intensive BP control significantly lowered the risk of death in patients with GFR <30 mL/min/1.73 m² (HR 0.73).
- Benefits for ESRD were also observed in patients with BMI ≥30 kg/m² (HR 0.75); however, intensive BP control did not show significant benefits for ESRD in patients with proteinuria <0.44 g/g or age <40 years, nor for death in patients with GFR ≥30 mL/min/1.73 m².
Conclusions:
- The benefits of intensive BP lowering on ESRD and all-cause mortality in CKD patients are not uniform across all subgroups.
- Specific subgroups, including those with higher proteinuria, lower GFR, older age, and obesity, appear to derive greater benefit from intensive BP control.
- Importantly, intensive BP lowering was not associated with an increased risk of ESRD or death in any of the examined subgroups.
Abstract:
Background Our objective was to explore the effect of intensive blood pressure (BP) control on kidney and death outcomes among subgroups of patients with chronic kidney disease divided by baseline proteinuria, glomerular filtration rate, age, and body mass index. Methods and Results We included 840 MDRD (Modification of Diet in Renal Disease) trial and 1067 AASK (African American Study of Kidney Disease and Hypertension) participants. We used Cox models to examine whether the association between intensive BP control and risk of end-stage renal disease (ESRD) or death is modified by baseline proteinuria (≥0.44 versus <0.44 g/g), glomerular filtration rate (≥30 versus <30 mL/min per 1.73 m2), age (≥40 versus <40 years), or body mass index (≥30 versus <30 kg/m2). The median follow-up was 14.9 years. Strict (versus usual) BP control was protective against ESRD (hazard ratio [HR]ESRD, 0.77; 95% CI, 0.64-0.92) among those with proteinuria ≥0.44 g/g but not proteinuria <0.44 g/g. Strict (versus usual) BP control was protective against death (HRdeath, 0.73; 95% CI, 0.59-0.92) among those with glomerular filtration rate <30 mL/min per 1.73 m2 but not glomerular filtration rate ≥30 mL/min per 1.73 m2 (HRdeath, 0.98; 95% CI, 0.84-1.15). Strict (versus usual) BP control was protective against ESRD among those ≥40 years (HRESRD, 0.82; 95% CI, 0.71-0.94) but not <40 years. Strict (versus usual) BP control was also protective against ESRD among those with body mass index ≥30 kg/m2 (HRESRD, 0.75; 95% CI, 0.61-0.92) but not body mass index <30 kg/m2. Conclusions The ESRD and all-cause mortality benefits of intensive BP lowering may not be uniform across all subgroups of patients with chronic kidney disease. But intensive BP lowering was not associated with increased risk of ESRD or death among any subgroups that we examined.
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