慢性血液透析患者的血压与心血管事件风险：CRIC研究（慢性肾功能不全队列研究）
Blood Pressure and Risk of Cardiovascular Events in Patients on Chronic Hemodialysis: The CRIC Study (Chronic Renal Insufficiency Cohort).
作者信息
Bansal Nisha, McCulloch Charles E, Lin Feng, Alper Arnold, Anderson Amanda H, Cuevas Magda, Go Alan S, Kallem Radhakrishna, Kusek John W, Lora Claudia M, Lustigova Eva, Ojo Akinlolu, Rahman Mahboob, Robinson-Cohen Cassianne, Townsend Raymond R, Wright Jackson, Xie Dawei, Hsu Chi-Yuan
机构信息
From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.).
出版信息
Hypertension. 2017 Aug;70(2):435-443. doi: 10.1161/HYPERTENSIONAHA.117.09091. Epub 2017 Jul 3.
We recently reported a linear association between higher systolic blood pressure (SBP) and risk of mortality in hemodialysis patients when SBP is measured outside of the dialysis unit (out-of-dialysis-unit-SBP), despite there being a U-shaped association between SBP measured at the dialysis unit (dialysis-unit-SBP) with risk of mortality. Here, we explored the relationship between SBP with cardiovascular events, which has important treatment implications but has not been well elucidated. Among 383 hemodialysis participants enrolled in the prospective CRIC study (Chronic Renal Insufficiency Cohort), multivariable splines and Cox models were used to study the association between SBP and adjudicated cardiovascular events (heart failure, myocardial infarction, ischemic stroke, and peripheral artery disease), controlling for differences in demographics, cardiovascular disease risk factors, and dialysis parameters. Dialysis-unit-SBP and out-of-dialysis-unit-SBP were modestly correlated (=0.34; <0.001). We noted a U-shaped association of dialysis-unit-SBP and risk of cardiovascular events, with the nadir risk between 140 and 170 mm Hg. In contrast, there was a linear stepwise association between out-of-dialysis-unit-SBP with risk of cardiovascular events. Participants with out-of-dialysis-unit-SBP ≥128 mm Hg (top 2 quartiles) had >2-fold increased risk of cardiovascular events compared with those with out-of-dialysis-unit-SBP ≤112 mm Hg (3rd SBP quartile: adjusted hazard ratio, 2.08 [95% confidence interval, 1.12-3.87] and fourth SBP quartile: adjusted hazard ratio, 2.76 [95% confidence interval, 1.42-5.33]). In conclusion, among hemodialysis patients, although there is a U-shaped (paradoxical) association of dialysis-unit-SBP and risk of cardiovascular disease, there is a linear association of out-of-dialysis-unit-SBP with risk of cardiovascular disease. Out-of-dialysis-unit blood pressure provides key information and may be an important therapeutic target.
我们最近报告称，当在透析单元外测量收缩压（SBP）时（透析单元外收缩压），血液透析患者的较高收缩压与死亡风险之间存在线性关联，尽管在透析单元测量的收缩压（透析单元收缩压）与死亡风险之间存在U型关联。在此，我们探讨了收缩压与心血管事件之间的关系，这对治疗具有重要意义，但尚未得到充分阐明。在纳入前瞻性CRIC研究（慢性肾功能不全队列）的383名血液透析参与者中，使用多变量样条和Cox模型研究收缩压与经判定的心血管事件（心力衰竭、心肌梗死、缺血性中风和外周动脉疾病）之间的关联，同时控制人口统计学、心血管疾病风险因素和透析参数的差异。透析单元收缩压和透析单元外收缩压之间存在适度相关性（=0.34；<0.001）。我们注意到透析单元收缩压与心血管事件风险之间存在U型关联，最低点风险在140至170 mmHg之间。相比之下，透析单元外收缩压与心血管事件风险之间存在线性逐步关联。透析单元外收缩压≥128 mmHg（最高两个四分位数）的参与者发生心血管事件的风险比透析单元外收缩压≤112 mmHg的参与者增加了2倍以上（第三个收缩压四分位数：调整后的风险比，2.08 [95%置信区间，1.12 - 3.87]；第四个收缩压四分位数：调整后的风险比，2.76 [95%置信区间，1.42 - 5.33]）。总之，在血液透析患者中，尽管透析单元收缩压与心血管疾病风险之间存在U型（矛盾的）关联，但透析单元外收缩压与心血管疾病风险之间存在线性关联。透析单元外血压提供了关键信息，可能是一个重要的治疗靶点。
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