Agarwal Rajiv, Light Robert P
1Division of Nephrology, Indiana University School of Medicine, Richard L Roudebush VA Medical Center, Indianapolis, IN, USA.
Nephrol Dial Transplant. 2009 Aug;24(8):2400-6. doi: 10.1093/ndt/gfp074. Epub 2009 Feb 27.
Hypertension is common, and arterial pressure rhythms are impaired in patients with chronic kidney disease (CKD). Emerging evidence suggests that consideration of excretory function together with proteinuria may provide a more holistic assessment of the extent of derangement in renal function.
To evaluate the independent relationships of estimated GFR and proteinuria with the mean level of and the circadian variation in blood pressure, we evaluated 336 patients, 184 (55%) patients with CKD (eGFR <60 or urine protein/creatinine >0.22) and 152 (45%) without CKD.
The mean level of systolic and diastolic BP increased with increasing severity of proteinuria as well as with increasing impairment in GFR. When proteinuria and eGFR were considered together in the same regression model, proteinuria-not eGFR-was related to the severity of hypertension. Non-dipping was present in 52% of those with eGFR >60 and 55% in those with no proteinuria. Non-dipping was seen early in the course of impaired GFR or proteinuria. Adjusted for proteinuria, the odds ratio for non-dipping in those with CKD was 1.71 (95% CI 1.03-2.84, P = 0.036). The odds ratio for non-dipping in those with proteinuria was 1.75 (95% CI 1.00-3.08, P = 0.049) when adjusted for CKD. A cosinor model that evaluates the midline estimating statistic of rhythm (MESOR) and circadian variation revealed that proteinuria was a stronger determinant of MESOR compared to the CKD stage; the CKD stage in addition to proteinuria did not further add to the determination of MESOR. The amplitude of variation was markedly blunted in patients with the earliest stages of derangement in kidney function whether it was assessed by proteinuria or eGFR.
These results demonstrate a graded relationship of proteinuria and eGFR with the mean level of BP and a non-graded relationship with circadian variation. Consideration of these two simple tests of renal function may better assist in gauging the severity of hypertension in patients with CKD.
高血压很常见，慢性肾脏病（CKD）患者的动脉压节律受损。新出现的证据表明，将排泄功能与蛋白尿一起考虑，可能会对肾功能紊乱程度提供更全面的评估。
为了评估估算的肾小球滤过率（GFR）和蛋白尿与血压平均水平及昼夜变化的独立关系，我们评估了336例患者，其中184例（55%）为CKD患者（估算肾小球滤过率<60或尿蛋白/肌酐>0.22），152例（45%）无CKD。
收缩压和舒张压的平均水平随着蛋白尿严重程度的增加以及GFR损害的加重而升高。当在同一回归模型中同时考虑蛋白尿和估算肾小球滤过率时，与估算肾小球滤过率相比，蛋白尿与高血压严重程度相关。估算肾小球滤过率>60的患者中52%存在非勺型血压，无蛋白尿患者中55%存在非勺型血压。在GFR受损或出现蛋白尿病程早期即可见到非勺型血压。校正蛋白尿后，CKD患者非勺型血压的比值比为1.71（95%可信区间1.03 - 2.84，P = 0.036）。校正CKD后，有蛋白尿患者非勺型血压的比值比为1.75（95%可信区间1.00 - 3.08，P = 0.049）。一个评估节律中线估计统计量（MESOR）和昼夜变化的余弦模型显示，与CKD分期相比，蛋白尿是MESOR更强的决定因素；除蛋白尿外，CKD分期并未进一步增加对MESOR的决定作用。无论通过蛋白尿还是估算肾小球滤过率评估，在肾功能紊乱最早阶段的患者中，变化幅度均明显减弱。
这些结果表明蛋白尿和估算肾小球滤过率与血压平均水平呈分级关系，与昼夜变化呈非分级关系。考虑这两项简单的肾功能检查可能有助于更好地评估CKD患者高血压的严重程度。
