Peralta Carmen A, Norris Keith C, Li Suying, Chang Tara I, Tamura Manjula K, Jolly Stacey E, Bakris George, McCullough Peter A, Shlipak Michael
Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA.
Arch Intern Med. 2012 Jan 9;172(1):41-7. doi: 10.1001/archinternmed.2011.619.
Treatment of hypertension is difficult in chronic kidney disease (CKD), and blood pressure goals remain controversial. The association between each blood pressure component and end-stage renal disease (ESRD) risk is less well known.
We studied associations of systolic and diastolic blood pressure (SBP and DBP, respectively) and pulse pressure (PP) with ESRD risk among 16,129 Kidney Early Evaluation Program (KEEP) participants with an estimated glomerular filtration rate of 60 mL/min/1.73 m(2) using Cox proportional hazards. We estimated the prevalence and characteristics associated with uncontrolled hypertension (SBP ≥ 150 or DBP ≥ 90 mm Hg).
The mean (SD) age of participants was 69 (12) years; 25% were black, 6% were Hispanic, and 43% had diabetes mellitus. Over 2.87 years, there were 320 ESRD events. Higher SBP was associated with higher ESRD risk, starting at SBP of 140 mm Hg or higher. After sex and age adjustment, compared with SBP lower than 130 mm Hg, hazard ratios (HRs) were 1.08 (95% CI, 0.74-1.59) for SBP of 130 to 139 mm Hg, 1.72 (95% CI, 1.21-2.45) for SBP of 140 to 149 mm Hg, and 3.36 (95% CI, 2.51-4.49) for SBP of 150 mm Hg or greater. After full adjustment, HRs for ESRD were 1.27 (95% CI, 0.88-1.83) for SBP of 140 to 149 mm Hg and 1.36 (95% CI, 1.02-1.85) for SBP of 150 mm Hg or higher. Persons with DBP of 90 mm Hg or higher were at higher risk for ESRD compared with persons with DBP of 60 to 74 mm Hg (HR, 1.81; 95% CI, 1.33-2.45). Higher PP was also associated with higher ESRD risk (HR, 1.44 [95% CI, 1.00-2.07] for PP ≥ 80 mm Hg compared with PP < 50 mm Hg). Adjustment for SBP attenuated this association. More than 33% of participants had uncontrolled hypertension (SBP ≥ 150 mm Hg or DBP ≥ 90 mm Hg), mostly due to isolated systolic hypertension (54%).
In this large, diverse, community-based sample, we found that high SBP seemed to account for most of the risk of progression to ESRD. This risk started at SBP of 140 mm Hg rather than the currently recommended goal of less than 130 mm Hg, and it was highest among those with SBP of at least 150 mm Hg. Treatment strategies that preferentially lower SBP may be required to improve BP control in CKD.
慢性肾脏病（CKD）患者的高血压治疗颇具难度，血压控制目标仍存在争议。各血压组分与终末期肾病（ESRD）风险之间的关联尚不明确。
我们采用Cox比例风险模型，研究了16129名肾脏早期评估项目（KEEP）参与者的收缩压和舒张压（分别为SBP和DBP）以及脉压（PP）与ESRD风险之间的关联，这些参与者的估算肾小球滤过率为60 mL/min/1.73 m²。我们估算了与未控制高血压（SBP≥150或DBP≥90 mmHg）相关的患病率及特征。
参与者的平均（标准差）年龄为69（12）岁；25%为黑人，6%为西班牙裔，43%患有糖尿病。在2.87年的随访期间，发生了320例ESRD事件。较高的SBP与较高的ESRD风险相关，SBP从140 mmHg及以上开始呈现这种关联。在对性别和年龄进行调整后，与SBP低于130 mmHg相比，SBP为130至139 mmHg时的风险比（HR）为1.08（95%CI，0.74 - 1.59），SBP为140至149 mmHg时的HR为1.72（95%CI，1.21 - 2.45），SBP为150 mmHg及以上时的HR为3.36（95%CI，2.51 - 4.49）。在进行全面调整后，SBP为140至149 mmHg时ESRD的HR为1.27（95%CI，0.88 - 1.83），SBP为150 mmHg及以上时的HR为1.36（95%CI，1.02 - 1.85）。与DBP为60至74 mmHg的人相比，DBP为90 mmHg及以上的人发生ESRD的风险更高（HR，1.81；95%CI，1.33 - 2.45）。较高的PP也与较高的ESRD风险相关（与PP < 50 mmHg相比，PP≥80 mmHg时的HR为1.44 [95%CI，1.00 - 2.07]）。对SBP进行调整后减弱了这种关联。超过33%的参与者患有未控制的高血压（SBP≥150 mmHg或DBP≥90 mmHg），主要原因是单纯收缩期高血压（54%）。
在这个大型、多样化的社区样本中，我们发现高SBP似乎是进展为ESRD的主要风险因素。这种风险在SBP达到140 mmHg时就已出现，而非目前推荐的低于130 mmHg的目标值，且在SBP至少为150 mmHg的人群中风险最高。可能需要优先降低SBP的治疗策略来改善CKD患者的血压控制。
