晚期肾病患者中血压与死亡、心血管事件及进展至慢性透析的关联
Association of BP with Death, Cardiovascular Events, and Progression to Chronic Dialysis in Patients with Advanced Kidney Disease.
作者信息
Palit Shyamal, Chonchol Michel, Cheung Alfred K, Kaufman James, Smits Gerard, Kendrick Jessica
机构信息
Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado;
Division of Nephrology & Hypertension, University of Utah, Salt Lake City, Utah; Renal Section, Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah; and.
出版信息
Clin J Am Soc Nephrol. 2015 Jun 5;10(6):934-40. doi: 10.2215/CJN.08620814. Epub 2015 May 15.
BACKGROUND AND OBJECTIVE
The optimal BP target to reduce adverse clinical outcomes in patients with CKD is unclear. This study examined the relationship between BP and death, cardiovascular events (CVEs), and kidney disease progression in patients with advanced kidney disease.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The relationship of systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) with death, CVE, and progression to long-term dialysis was examined in 1099 patients with advanced CKD (eGFR≤30 ml/min per 1.7 3m(2); not receiving dialysis) who participated in the Homocysteine in Kidney and ESRD study. That study enrolled participants from 2001 to 2003. Cox proportional hazard models were used to examine the association between BP and adverse outcomes.
RESULTS
The mean±SD baseline eGFR was 18±7 ml/min per 1.73 m(2). During a median follow-up of 2.9 years, 453 patients died, 215 had a CVE, and 615 initiated long-term dialysis. After adjustment for demographic characteristics and confounders, SBP, DBP, and PP were not associated with a higher risk of death. SBP and DBP were also not associated with CVE. The highest quartile of PP was associated with a substantial higher risk of CVE compared with the lowest quartile (hazard ratio [HR], 1.67; 95% confidence interval [95% CI], 1.10 to 2.52). The highest quartiles of SBP (HR, 1.28; 95% CI, 1.01 to 1.61) and DBP (HR, 1.36; 95% CI, 1.07 to 1.73), but not PP, were associated with a higher risk of progression to long-term dialysis compared with the lowest quartile.
CONCLUSIONS
In patients with advanced kidney disease not undergoing dialysis, higher PP was strongly associated with CVE whereas higher SBP and DBP were associated with progression to long-term dialysis. These results suggest that SBP and DBP should not be the only factors considered in determining antihypertensive therapy; elevated PP should also be considered.
背景与目的
降低慢性肾脏病（CKD）患者不良临床结局的最佳血压目标尚不清楚。本研究探讨了晚期肾病患者血压与死亡、心血管事件（CVE）及肾病进展之间的关系。
设计、地点、参与者及测量方法：在1099例晚期CKD患者（估算肾小球滤过率[eGFR]≤30 ml/min/1.73m²；未接受透析）中，研究收缩压（SBP）、舒张压（DBP）和脉压（PP）与死亡、CVE及进展至长期透析之间的关系。这些患者参与了“肾脏与终末期肾病中的同型半胱氨酸”研究。该研究于2001年至2003年招募参与者。采用Cox比例风险模型来研究血压与不良结局之间的关联。
结果
平均±标准差的基线eGFR为18±7 ml/min/1.73m²。在中位随访2.9年期间，453例患者死亡，215例发生CVE，615例开始长期透析。在对人口统计学特征和混杂因素进行校正后，SBP、DBP和PP与更高的死亡风险无关。SBP和DBP也与CVE无关。与最低四分位数相比，PP的最高四分位数与显著更高的CVE风险相关（风险比[HR]，1.67；95%置信区间[95%CI]，1.10至2.52）。与最低四分位数相比，SBP（HR，1.28；95%CI，1.01至1.61）和DBP（HR，1.36；95%CI，1.07至1.73）的最高四分位数与进展至长期透析的更高风险相关，但PP与长期透析进展无关。
结论
在未接受透析的晚期肾病患者中，较高的PP与CVE密切相关，而较高的SBP和DBP与进展至长期透析相关。这些结果表明，在确定抗高血压治疗时，SBP和DBP不应是唯一考虑的因素；升高的PP也应予以考虑。
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