Minutolo Roberto, Agarwal Rajiv, Borrelli Silvio, Chiodini Paolo, Bellizzi Vincenzo, Nappi Felice, Cianciaruso Bruno, Zamboli Pasquale, Conte Giuseppe, Gabbai Francis B, De Nicola Luca
Department of Nephrology, Second University of Naples, Naples, Italy.
Arch Intern Med. 2011 Jun 27;171(12):1090-8. doi: 10.1001/archinternmed.2011.230.
Ambulatory blood pressure (BP) measurement allows a better risk stratification in essential hypertension compared with office blood pressure measurement, but its prognostic role in nondialysis chronic kidney disease has been poorly investigated.
The prognostic role of daytime and nighttime systolic BP (SBP) and diastolic BP (DBP) in comparison with office measurements was evaluated in 436 consecutive patients with chronic kidney disease. Primary end points were time to renal death (end-stage renal disease or death) and time to fatal and nonfatal cardiovascular events. Quintiles of BP were used to classify patients.
The mean (SD) age of the patients was 65.1 (13.6) years, and the glomerular filtration rate was 42.9 (19.7) mL/min/1.73 m(2); 41.7% of the participants were women, 36.5% had diabetes, and 30.5% had cardiovascular disease. Office-measured SBP/DBP values were 146 (19)/82 (12) mm Hg; daytime SBP/DBP was 131 (17)/75 (11) mm Hg, and nighttime SBP/DBP was 122 (20)/66 (10) mm Hg. During follow-up (median, 4.2 years), 155 and 103 patients reached the renal and cardiovascular end points, respectively. Compared with a daytime SBP of 126 to 135 mm Hg, patients with an SBP of 136 to 146 mm Hg and those with an SBP higher than 146 mm Hg had an increased adjusted risk of the cardiovascular end point (hazard ratio [HR], 2.23; 95% confidence interval [CI], 1.13-4.41 and 3.07; 1.54-6.09) and renal death (1.72; 1.02-2.89 and 1.85; 1.11-3.08). Nighttime SBPs of 125 to 137 mm Hg and higher than 137 mm Hg also increased the risk of the cardiovascular end point (HR, 2.52; 95% CI, 1.11-5.71 and 4.00; 1.77-9.02) and renal end point (1.87; 1.03-3.43 and 2.54; 1.41-4.57) with respect to the reference SBP value of 106-114 mm Hg. Office measurement of BP did not predict the risk of the renal or cardiovascular end point. Patients who were nondippers and those who were reverse dippers had a greater risk of both end points.
In chronic kidney disease, ambulatory BP measurement and, in particular, nighttime BP measurement, allows more accurate prediction of renal and cardiovascular risk; office measurement of BP does not predict any outcome.
与诊室血压测量相比，动态血压测量能更好地对原发性高血压进行风险分层，但其在非透析慢性肾脏病中的预后作用研究较少。
对436例连续性慢性肾脏病患者评估了日间和夜间收缩压（SBP）及舒张压（DBP）与诊室测量值相比的预后作用。主要终点为肾脏死亡时间（终末期肾病或死亡）以及致命和非致命心血管事件发生时间。采用血压五分位数对患者进行分类。
患者的平均（标准差）年龄为65.1（13.6）岁，肾小球滤过率为42.9（19.7）ml/min/1.73m²；41.7%的参与者为女性，36.5%患有糖尿病，30.5%患有心血管疾病。诊室测量的SBP/DBP值为146（19）/82（12）mmHg；日间SBP/DBP为131（17）/75（11）mmHg，夜间SBP/DBP为122（20）/66（10）mmHg。在随访期间（中位数为4.2年），分别有155例和103例患者达到肾脏和心血管终点。与日间SBP为126至135mmHg相比，SBP为136至146mmHg以及高于146mmHg的患者发生心血管终点的校正风险增加（风险比[HR]，2.23；95%置信区间[CI]，1.13 - 4.41和3.07；1.54 - 6.09）以及肾脏死亡风险增加（1.72；1.02 - 2.89和1.85；1.11 - 3.08）。夜间SBP为125至137mmHg以及高于137mmHg与参考SBP值106 - 114mmHg相比，也增加了心血管终点风险（HR，2.52；95%CI，1.11 - 5.71和4.00；1.77 - 9.02）以及肾脏终点风险（1.87；1.03 - 3.43和2.54；1.41 - 4.57）。诊室血压测量不能预测肾脏或心血管终点风险。非勺型血压者和反勺型血压者发生两种终点的风险更高。
在慢性肾脏病中，动态血压测量，尤其是夜间血压测量，能更准确地预测肾脏和心血管风险；诊室血压测量不能预测任何结局。
