Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours Cedex, France.
EA4245, François-Rabelais University, Tours, France.
BMC Nephrol. 2022 Jan 20;23(1):39. doi: 10.1186/s12882-022-02672-3.
The impact of blood pressure on neurological symptoms and risk of end-stage kidney disease (ESKD) is unknown in primary and secondary thrombotic microangiopathies (TMAs).
We measured baseline systolic (SBP) and diastolic (DBP) BP in consecutive 563 patients with adjudicated primary and secondary TMAs, and assessed its association with the risk of ESKD.
Normal BP, grade 1, 2 and 3 hypertension were present in 243 (43.1%), 132 (23.4%), 101 (17.9%) and 88 (15.6%), respectively. Significant BP differences were noted in relation to the cause of TMA: highest BP values were found in patients with atypical hemolytic-uremic syndrome (aHUS), pregnancy, transplantation and auto-immune-related TMAs. Normal BP or grade 1 hypertension was found in 17/18 (94.4%) patients with thrombotic thrombocytopenic patients (only 1/18 (5.6%) had a SBP value>150 mmHg). In contrast, BP values could not differentiate isolated "essential" malignant hypertension (MH) from MH associated with aHUS (isolated MH (n=15): BP (median (IQR)): 220 (182-249)/132 (101-150) mmHg; MH with aHUS (n=5): BP: 223 (196-245)/131 (111-144) mmHg). The risk of vigilance disturbances (6.9%, 15.0%, 25.0%, respectively), epileptic seizures (1.5%, 4.0%, 12.5%, respectively) and posterior reversible encephalopathy syndrome (0.76%, 2.97%, 6.82%, respectively) increased with increasing baseline BP values from grade 1 to grade 3 hypertension. ESKD occurred in 35/563 (6.2%) patients (1.23%, 2.27%, 11.9% and 19.3% of patients with normal BP, grade 1, 2 and 3 hypertension, respectively). As compared to patients with normal BP (<120/139 mmHg), grade 1, grade 2 and grade 3 hypertension were associated with a greater risk of ESKD in univariate (OR: 1.91 [0.83-4.40], 13.2 [3.56-48.9] and 34.8 [9.31-130], respectively) and multivariate (OR: 0.89 [0.30-2.69], 7.00 [1.57-31.3] and 19.7 [4.53-85.2], respectively) analyses. The association between BP and the risk of ESRD was unchanged after adjustment on eculizumab use (OR: 3.46 [1.41-8.49], 17.7 [4.44-70.0] and 70.6 [8.61-579], respectively). Patients with MH, regardless of its cause, had a greater risk of ESKD (OR: 26.4 [10.0-69.8] vs other patients).
Baseline BP differs in primary and secondary TMAs. High BP reduces the neurological tolerance of TMAs and is a powerful independent risk factor of ESKD, even after adjustment on TMA's cause.
原发性和继发性血栓性微血管病（TMA）中血压对神经症状和终末期肾病（ESKD）风险的影响尚不清楚。
我们在连续的 563 例明确诊断的原发性和继发性 TMA 患者中测量了基线收缩压（SBP）和舒张压（DBP），并评估了其与 ESKD 风险的关系。
正常血压、1 级、2 级和 3 级高血压分别见于 243（43.1%）、132（23.4%）、101（17.9%）和 88（15.6%）例患者。与 TMA 的病因有关的血压差异显著：最高的血压值见于非典型溶血尿毒综合征（aHUS）、妊娠、移植和自身免疫相关 TMA 患者。在孤立性“特发性”恶性高血压（MH）与 MH 合并 aHUS 中，BP 值不能区分孤立性“特发性”恶性高血压（仅 18 例（5.6%）中 1 例 SBP 值>150mmHg）。相比之下，血压值不能区分孤立性“特发性”恶性高血压（MH）与 MH 合并 aHUS（孤立性 MH（n=15）：BP（中位数（IQR））：220（182-249）/132（101-150）mmHg；MH 合并 aHUS（n=5）：BP：223（196-245）/131（111-144）mmHg）。从 1 级高血压到 3 级高血压，随着基线 BP 值的升高，警觉障碍（分别为 6.9%、15.0%、25.0%）、癫痫发作（分别为 1.5%、4.0%、12.5%）和后部可逆性脑病综合征（分别为 0.76%、2.97%、6.82%）的风险增加。在 563 例患者中，有 35 例（6.2%）发生 ESKD（正常血压组为 1.23%、1 级高血压组为 2.27%、2 级高血压组为 11.9%、3 级高血压组为 19.3%）。与正常血压（<120/139mmHg）相比，1 级、2 级和 3 级高血压与 ESKD 的风险在单因素（OR：1.91[0.83-4.40]、13.2[3.56-48.9]和 34.8[9.31-130]）和多因素（OR：0.89[0.30-2.69]、7.00[1.57-31.3]和 19.7[4.53-85.2]）分析中均相关。在调整依库珠单抗使用后，BP 与 ESRD 风险之间的关联保持不变（OR：3.46[1.41-8.49]、17.7[4.44-70.0]和 70.6[8.61-579]）。无论其病因如何，MH 患者发生 ESKD 的风险均较高（OR：26.4[10.0-69.8]vs 其他患者）。
原发性和继发性 TMA 中的基线 BP 不同。高血压降低了 TMA 的神经耐受性，是 ESKD 的一个强大的独立危险因素，即使在调整了 TMA 的病因后也是如此。
