Division of Nephrology, Department of Medicine,
Division of Pediatric Nephrology, Department of Pediatrics, and.
J Am Soc Nephrol. 2018 Sep;29(9):2401-2408. doi: 10.1681/ASN.2018040365. Epub 2018 Jul 13.
During intensive BP lowering, acute declines in renal function are common, thought to be hemodynamic, and potentially reversible. We previously showed that acute declines in renal function ≥20% during intensive BP lowering were associated with higher risk of ESRD. Here, we determined whether acute declines in renal function during intensive BP lowering were associated with mortality risk among 1660 participants of the African American Study of Kidney Disease and Hypertension and the Modification of Diet in Renal Disease Trial.
We used Cox models to examine the association between percentage decline in eGFR (<5%, 5% to <20%, or ≥20%) between randomization and months 3-4 of the trials (period of therapy intensification) and death.
In adjusted analyses, compared with a <5% eGFR decline in the usual BP arm (reference), a 5% to <20% eGFR decline in the intensive BP arm was associated with a survival benefit (hazard ratio [HR], 0.77; 95% confidence interval [95% CI], 0.62 to 0.96), but a 5% to <20% eGFR decline in the usual BP arm was not (HR, 1.01; 95% CI, 0.81 to 1.26; <0.05 for the interaction between intensive and usual BP arms for mortality risk). A ≥20% eGFR decline was not associated with risk of death in the intensive BP arm (HR, 1.18; 95% CI, 0.86 to 1.62), but it was associated with a higher risk of death in the usual BP arm (HR, 1.40; 95% CI, 1.04 to 1.89) compared with the reference group.
Intensive BP lowering was associated with a mortality benefit only if declines in eGFR were <20%.
在强化降压期间，肾功能的急性下降很常见，被认为是血液动力学的，并可能是可逆的。我们之前的研究表明，在强化降压过程中肾功能急性下降≥20%与终末期肾病风险增加相关。在这里，我们确定在强化降压期间肾功能的急性下降是否与非洲裔美国人肾脏病和高血压研究以及肾脏疾病饮食改良试验的 1660 名参与者的死亡率风险相关。
我们使用 Cox 模型来研究随机分组和试验的第 3-4 个月（治疗强化期间）eGFR（<5%、5%-<20%或≥20%）下降百分比与死亡之间的关联。
在调整后的分析中，与常规血压组（参考）的 eGFR 下降<5%相比，强化血压组的 eGFR 下降 5%-<20%与生存获益相关（危险比 [HR]，0.77；95%置信区间 [95%CI]，0.62 至 0.96），但常规血压组的 eGFR 下降 5%-<20%并不相关（HR，1.01；95%CI，0.81 至 1.26；强化和常规血压组之间的死亡率风险无交互作用<0.05）。强化血压组 eGFR 下降≥20%与死亡风险无关（HR，1.18；95%CI，0.86 至 1.62），但与参考组相比，常规血压组 eGFR 下降≥20%与死亡风险增加相关（HR，1.40；95%CI，1.04 至 1.89）。
只有 eGFR 下降<20%时，强化降压才与死亡率获益相关。
