Sumida Keiichi, Molnar Miklos Z, Potukuchi Praveen K, Thomas Fridtjof, Lu Jun Ling, Yamagata Kunihiro, Kalantar-Zadeh Kamyar, Kovesdy Csaba P
aDivision of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA bNephrology Center, Toranomon Hospital Kajigaya, Kawasaki, Kanagawa cDepartment of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan dDepartment of Transplantation and Surgery, Semmelweis University, Budapest, Hungary eDivision of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee fDivision of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, California gNephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA.
J Hypertens. 2017 Sep;35(9):1816-1824. doi: 10.1097/HJH.0000000000001376.
Higher SBP visit-to-visit variability (SBPV) has been associated with increased risk of adverse events in patients with chronic kidney disease, but the association of SBPV in advanced nondialysis-dependent chronic kidney disease with mortality after the transition to end-stage renal disease (ESRD) remains unknown.
Among 17 729 US veterans transitioning to dialysis between October 2007 and September 2011, we assessed SBPV calculated from the SD of at least three intraindividual outpatient SBP values during the last year prior to dialysis transition (prelude period). Outcomes included factors associated with higher prelude SBPV and post-transition all-cause, cardiovascular, and infection-related mortality, assessed using multivariable linear regression and Cox and competing risk regressions, respectively, adjusted for demographics, comorbidities, medications, cardiovascular medication adherence, SBP, BMI, estimated glomerular filtration rate, and type of vascular access.
Modifiable clinical factors associated with higher prelude SBPV included higher SBP, use of antihypertensive medications and erythropoiesis-stimulating agents, inadequate cardiovascular medication adherence, and catheter use. After multivariable adjustment, higher prelude SBPV was significantly associated with higher post-ESRD all-cause and infection-related mortality, but not cardiovascular mortality [hazard/subhazard ratios (95% confidence interval) for the highest (vs. lowest) quartile of SBPV, 1.08 (1.01-1.16), 1.02 (0.89-1.15), and 1.41 (1.10-1.80) for all-cause, cardiovascular, and infection-related mortality, respectively].
High pre-ESRD SBPV is potentially modifiable and associated with higher all-cause and infection-related mortality following dialysis initiation. Further studies are needed to test whether modification of pre-ESRD SBPV can improve clinical outcomes in incident ESRD patients. VIDEO ABSTRACT:.
血压（SBP）就诊间变异性（SBPV）升高与慢性肾脏病患者不良事件风险增加相关，但晚期非透析依赖型慢性肾脏病患者的SBPV与转为终末期肾病（ESRD）后的死亡率之间的关联尚不清楚。
在2007年10月至2011年9月期间转为透析的17729名美国退伍军人中，我们评估了透析转换前一年（前期）至少三个个体门诊SBP值的标准差计算得出的SBPV。结局包括与前期较高SBPV相关的因素以及转换后全因、心血管和感染相关死亡率，分别使用多变量线性回归以及Cox回归和竞争风险回归进行评估，并对人口统计学、合并症、药物治疗、心血管药物依从性、SBP、体重指数、估计肾小球滤过率和血管通路类型进行了校正。
与前期较高SBPV相关的可改变临床因素包括较高的SBP、使用抗高血压药物和促红细胞生成素、心血管药物依从性不足以及使用导管。多变量校正后，较高的前期SBPV与ESRD后较高的全因和感染相关死亡率显著相关，但与心血管死亡率无关[SBPV最高（与最低）四分位数的风险/亚风险比（95%置信区间），全因、心血管和感染相关死亡率分别为1.08（1.01-1.16）、1.02（0.89-1.15）和1.41（1.10-1.80）]。
ESRD前高SBPV具有潜在可改变性，且与透析开始后较高的全因和感染相关死亡率相关。需要进一步研究以检验调整ESRD前SBPV是否可改善初发ESRD患者的临床结局。视频摘要：。
