Shulman N B, Ford C E, Hall W D, Blaufox M D, Simon D, Langford H G, Schneider K A
Emory University School of Medicine, Atlanta, Georgia.
Hypertension. 1989 May;13(5 Suppl):I80-93. doi: 10.1161/01.hyp.13.5_suppl.i80.
The Hypertension Detection and Follow-up Program followed up 10,940 persons for 5 years in a community-based, randomized, controlled trial of treatment for hypertension. Participants were randomized to one of two treatment groups, stepped care and referred care. The primary end point of the study was all-cause mortality, with morbid events involving the heart, brain, and kidney as secondary end points. Loss of renal function, ascertained by a change in serum creatinine, was among these secondary events. Baseline serum creatinine concentration had a significant prognostic value for 8-year mortality. For persons with a serum creatinine concentration greater than or equal to 1.7 mg/dl, 8-year mortality was more than three times that of all other participants. The estimated 5-year incidence of substantial decline in renal function was 21.7/1,000 in the stepped-care group and 24.6/1,000 in the referred-care group. Among persons with a baseline serum creatinine level between 1.5 and 1.7 mg/dl, the 5-year incidence of decline was 113.3/1,000 (stepped care) and 226.6/1,000 (referred care) (p less than 0.01). The incidence of decline in renal function was greater in men, blacks, and older adults, as well as in those with higher entry diastolic blood pressure. Among persons with a baseline serum creatinine level greater than or equal to 1.7 mg/dl, serum creatinine concentration declined by 25% or more in 28.6% of stepped-care and 25.2% of referred-care participants. Although the incidence of clinically significant hypercreatininemia in a hypertensive population is low, an elevated serum creatinine concentration is a very potent independent risk factor for mortality. The slightly lower rate of development of hypercreatininemia and the higher rate of improvement in stepped-care compared with referred-care participants is consistent with the belief that aggressive treatment of hypertension may reduce renal damage and the associated increased risk of death.
高血压检测与随访项目在一项基于社区的高血压治疗随机对照试验中，对10940人进行了为期5年的随访。参与者被随机分为两个治疗组之一，即阶梯式护理组和转诊护理组。该研究的主要终点是全因死亡率，涉及心脏、大脑和肾脏的发病事件作为次要终点。通过血清肌酐变化确定的肾功能丧失属于这些次要事件。基线血清肌酐浓度对8年死亡率具有显著的预后价值。对于血清肌酐浓度大于或等于1.7mg/dl的人，8年死亡率是所有其他参与者的三倍多。阶梯式护理组肾功能大幅下降的估计5年发病率为21.7/1000，转诊护理组为24.6/1000。在基线血清肌酐水平在1.5至1.7mg/dl之间的人群中，5年下降发病率为113.3/1000（阶梯式护理）和226.6/1000（转诊护理）（p小于0.01）。男性、黑人、老年人以及入院时舒张压较高的人群中肾功能下降的发生率更高。在基线血清肌酐水平大于或等于1.7mg/dl的人群中，28.6%的阶梯式护理参与者和25.2%的转诊护理参与者血清肌酐浓度下降了25%或更多。尽管高血压人群中具有临床意义的高肌酐血症发病率较低，但血清肌酐浓度升高是一个非常强大的独立死亡风险因素。与转诊护理参与者相比，阶梯式护理参与者中高肌酐血症的发生率略低且改善率较高，这与积极治疗高血压可能减少肾脏损害及相关死亡风险增加的观点一致。
