Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
Clin Exp Nephrol. 2023 Jun;27(6):542-547. doi: 10.1007/s10157-023-02341-1. Epub 2023 Mar 22.
The revised KDIGO guidelines recommend maintaining systolic blood pressure (sBP) < 120 mmHg in patients with chronic kidney disease (CKD), based on cardiovascular and survival benefits. However, the renal benefit of this strategy remains less clear.
We used data of routine health checkups in Japan. Persons whose estimated glomerular filtration rate (eGFR) was < 60 mL/min/1.73 m in 2015 without end-stage disease were followed until 2020. We estimated the 5-year benefit of hypothetical targeted sBP control using parametric g-formula modeling, accounting for both time-fixed and time-varying confounding variables. Four sensitivity analyses, including analysis using a marginal structural model (MSM) and positive control outcome analysis, were also done.
We enrolled 28,972 persons with CKD (median age: 54 years, male: 69%, baseline eGFR [median]: 56 mL/min/1.73m). As compared with the natural course without a targeted intervention, there was no renoprotective effect of targeted sBP control, with a 5-year difference in eGFR of 0.65 mL/min/1.73 m (95% confidence interval - 0.42 to 1.65 mL/min/1.73 m). MSM analysis found a similar result. In contrast, the positive control analysis using the cardiovascular outcome showed that targeted sBP control would reduce the cardiovascular disease incidence by 6.0% over 5 years.
A targeted sBP control strategy maintaining < 120 mmHg may not yield a renoprotective effect for patients with stage 3-4 CKD, although it was expected to offer a cardiovascular benefit. Future research may be warranted in higher-risk populations, such as elderly people or those with more advanced kidney disease.
根据心血管和生存获益，KDIGO 修订指南建议慢性肾脏病（CKD）患者的收缩压（sBP）<120mmHg。然而，这种策略的肾脏获益尚不清楚。
我们使用了日本常规健康检查的数据。2015 年估算肾小球滤过率（eGFR）<60ml/min/1.73m 且无终末期疾病的患者在 2020 年之前被随访。我们使用参数 g 公式建模来估计假设的目标 sBP 控制的 5 年获益，同时考虑了时间固定和时间变化的混杂变量。还进行了四项敏感性分析，包括使用边际结构模型（MSM）和阳性对照结果分析的分析。
我们纳入了 28972 例 CKD 患者（中位年龄：54 岁，男性：69%，基线 eGFR[中位数]：56ml/min/1.73m）。与无目标干预的自然病程相比，目标 sBP 控制没有肾脏保护作用，eGFR 在 5 年内的差异为 0.65ml/min/1.73m（95%置信区间-0.42 至 1.65ml/min/1.73m）。MSM 分析得出了类似的结果。相比之下，使用心血管结局的阳性对照分析表明，目标 sBP 控制可在 5 年内将心血管疾病的发生率降低 6.0%。
对于 3-4 期 CKD 患者，维持<120mmHg 的目标 sBP 控制策略可能不会产生肾脏保护作用，尽管预计会带来心血管获益。可能需要在更高风险的人群中进行进一步研究，例如老年人或更晚期肾病患者。
