Sood Manish M, Akbari Ayub, Manuel Douglas G, Ruzicka Marcel, Hiremath Swapnil, Zimmerman Deborah, McCormick Brendan, Taljaard Monica
From the Division of Nephrology, Department of Medicine (M.M.S., A.A., M.R., S.H., D.Z., B.M.), Ottawa Hospital Research Institute, The Ottawa Hospital (M.M.S., D.G.M.), Institute for Clinical Evaluative Sciences (M.M.S., M.T.), Department of Family Medicine (D.G.M.), and School of Epidemiology, Public Health and Preventative Medicine (A.A., D.G.M., M.T.), University of Ottawa, ON, Canada.
Hypertension. 2017 Dec;70(6):1210-1218. doi: 10.1161/HYPERTENSIONAHA.117.09855. Epub 2017 Oct 23.
Whether different methods of quantitating blood pressure (BP) in late chronic kidney disease better mimic pathophysiological processes and clinical outcomes remains unclear. In a retrospective study, we determined the association of BP with end-stage kidney disease (ESKD) and all-cause mortality with BP modeled at baseline versus longitudinally with time-varying Cox models as (1) current (most recent) clinic visit, (2) lag (visit immediately preceding the current), (3) cumulative (average of previous measurements), and (4) change from baseline to the most recent. Among 1203 (6913 visits) study patients, the mean age and baseline estimated glomerular filtration rate were 66 and 18 mL·min·1.73 m), and 40% were female. Patients had a mean of 6.7 BP measurements, 540 (44.8%) reached ESKD, and 141 (11.7%) died. For systolic BP >160, current (hazard ratio [HR], 1.67), cumulative (HR, 1.58), and a rise to >160 from baseline 120 to 160 (HR, 1.60) were associated with ESKD. Similarly, diastolic BP >85 was associated with ESKD when modeled as current (HR, 1.47), lag (HR, 1.63), cumulative (HR, 2.15), or change from baseline (rise to >85 from a baseline of 60-85; HR, 1.62). Both low SBP (<120), when modeled as current (HR, 1.59), cumulative exposure (HR, 1.76), persistently <120 (HR, 2.28), and high SBP (>140), when modeled as cumulative exposure, were associated with all-cause mortality. For diastolic BP, only cumulative >85 was significantly associated with mortality (HR, 2.75). Thus, in late-stage chronic kidney disease, persistently high or rises in systolic BP or diastolic BP are associated with risk of ESKD, whereas baseline BP measures did not convey information on risk.
在晚期慢性肾病中，不同的血压（BP）定量方法是否能更好地模拟病理生理过程和临床结局仍不清楚。在一项回顾性研究中，我们使用时变Cox模型，以（1）当前（最近一次）门诊就诊时的血压、（2）滞后血压（当前就诊前一次就诊时的血压）、（3）累积血压（先前测量值的平均值）以及（4）从基线到最近一次测量的血压变化为模型，确定了血压与终末期肾病（ESKD）以及全因死亡率之间的关联。在1203名（共6913次就诊）研究患者中，平均年龄和基线估计肾小球滤过率分别为66岁和18 mL·min·1.73 m²，40%为女性。患者平均进行了6.7次血压测量，540名（44.8%）患者发展为ESKD，141名（11.7%）患者死亡。对于收缩压>160，当前血压（风险比[HR]，1.67）、累积血压（HR，1.58）以及从基线120上升至>160（HR，1.60）与ESKD相关。同样，当以当前血压（HR，1.47）、滞后血压（HR，1.63）、累积血压（HR，2.15）或从基线变化（从60 - 85的基线上升至>85；HR，1.62）为模型时，舒张压>85与ESKD相关。收缩压低（<120），以当前血压（HR，1.59）、累积暴露（HR，1.76）、持续<120（HR，2.28）为模型时，以及收缩压高（>140），以累积暴露为模型时，均与全因死亡率相关。对于舒张压，仅累积>85与死亡率显著相关（HR，2.75）。因此，在晚期慢性肾病中，收缩压或舒张压持续升高或上升与ESKD风险相关，而基线血压测量并不能传达风险信息。
