Imai Enyu, Ito Sadayoshi, Haneda Masakazu, Harada Atsushi, Kobayashi Fumiaki, Yamasaki Tetsu, Makino Hirofumi, Chan Juliana C N
Nakayamadera Imai Clinic, Takarazuka, Japan Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
Division of Nephrology, Endocrinology, and Vascular Medicine, Department of Clinical Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
Nephrol Dial Transplant. 2016 Mar;31(3):447-54. doi: 10.1093/ndt/gfv272. Epub 2015 Jul 6.
Blood pressure (BP) control may have different effects on cardiovascular (CV) and renal outcomes in diabetes. We examined the impact of systolic BP (SBP) on renal and CV outcomes in a post hoc analysis in the Olmesartan Reducing Incidence of Endstage Renal Disease in Diabetic Nephropathy Trial.
We stratified mean follow-up SBP into three categories (≤130, 131-140 and >140 mmHg) and used a Cox regression model to estimate the hazard ratio (HR, 95% confidence interval) for the outcomes. The composite renal outcome was doubling of serum creatinine, end-stage renal disease and all-cause death. The composite CV outcome included CV death, nonfatal stroke, nonfatal myocardial infarction, hospitalization for unstable angina or heart failure, revascularization and lower extremity amputation. We also compared the slope of estimated glomerular filtration rate (eGFR) in all three groups.
After a mean follow-up period of 3.2 years, the follow-up SBP was linearly associated with risk of renal outcomes in all 566 patients. In patients with heavy proteinuria (≥1 g/gCr), a follow-up SBP > 130 mmHg was associated with an HR of 2.33 (1.62-3.36) for renal outcomes with referent to SBP ≤ 130 mmHg. In patients without history of CV disease, a follow-up SBP > 140 mmHg was associated with an HR of 2.04 (1.23-3.40) for CV outcomes with referent to SBP < 140 mmHg. The median (interquartile range) slopes of eGFR were -3.27 (-6.90, -1.63), -4.53 (-8.08, -2.29) and -7.13 (-10.90, -3.99) dL/mg/year in patients with SBP ≤ 130, 131-140 and > 140 mmHg, respectively (P = 0.008 between ≤130 and 131-140, P < 0.001 between ≤ 130 and > 140 mmHg).
In Asian type 2 diabetic patients with chronic kidney disease and heavy proteinuria, reduction of SBP ≤ 130 mmHg was associated with greater renoprotection than cardioprotection. However, our results emphasize the need to individualize BP targets in type 2 diabetes.
血压（BP）控制对糖尿病患者的心血管（CV）和肾脏结局可能有不同影响。我们在奥美沙坦降低糖尿病肾病终末期肾病发病率试验的事后分析中，研究了收缩压（SBP）对肾脏和CV结局的影响。
我们将平均随访SBP分为三类（≤130、131 - 140和>140 mmHg），并使用Cox回归模型估计结局的风险比（HR，95%置信区间）。复合肾脏结局为血清肌酐翻倍、终末期肾病和全因死亡。复合CV结局包括CV死亡、非致死性卒中、非致死性心肌梗死、因不稳定型心绞痛或心力衰竭住院、血管重建和下肢截肢。我们还比较了三组中估计肾小球滤过率（eGFR）的斜率。
平均随访3.2年后，在所有566例患者中，随访SBP与肾脏结局风险呈线性相关。在重度蛋白尿（≥1 g/gCr）患者中，随访SBP>130 mmHg时，肾脏结局的HR为2.33（1.62 - 3.36），以SBP≤130 mmHg为参照。在无CV疾病史的患者中，随访SBP>140 mmHg时，CV结局的HR为2.04（1.23 - 3.40），以SBP<140 mmHg为参照。SBP≤130、131 - 140和>140 mmHg的患者中，eGFR的中位数（四分位间距）斜率分别为-3.27（-6.90，-1.63）、-4.53（-8.08，-2.29）和-7.13（-10.90，-3.99）dL/mg/年（SBP≤130与131 - 140之间P = 0.008，SBP≤130与>140 mmHg之间P<0.001）。
在患有慢性肾病和重度蛋白尿的亚洲2型糖尿病患者中，将SBP降至≤130 mmHg对肾脏的保护作用大于对心脏的保护作用。然而，我们的结果强调了2型糖尿病患者血压目标个体化的必要性。
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