Costes-Albrespic Margaux, Liabeuf Sophie, Laville Solène, Jacquelinet Christian, Combe Christian, Fouque Denis, Laville Maurice, Frimat Luc, Pecoits-Filho Roberto, Lambert Oriane, Massy Ziad A, Sautenet Bénédicte, Alencar de Pinho Natalia
Centre for Research in Epidemiology and Population Health, Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France.
Pharmaco-epidemiology Unit, Department of Clinical Pharmacology, Amiens-Picardie University Medical Center, Amiens, France.
Kidney Med. 2024 Oct 9;6(12):100912. doi: 10.1016/j.xkme.2024.100912. eCollection 2024 Dec.
RATIONALE & OBJECTIVE: Blood pressure (BP) control is essential for preventing cardiorenal complications in chronic kidney disease (CKD), but most patients fail to reach BP target. We assessed longitudinal patterns of antihypertensive drug prescription and systolic BP.
Prospective observational cohort study.
SETTING & POPULATION: In total, 2,755 hypertensive patients with CKD stages 3-4, receiving care from a nephrologist, from the French CKD-Renal Epidemiology and Information Network (CKD-REIN cohort study).
Patient factors, including sociodemographic characteristics, medical history, and laboratory data, and provider factors, including number of primary care physician and specialist encounters.
Changes in antihypertensive drug-class prescription during follow-up: add-on or withdrawal.
Hierarchical shared-frailty models to estimate hazard ratios (HR) to deal with clustering at the nephrologist level and linear mixed models to describe systolic BP trajectory.
At baseline, median age was 69 years, and mean estimated glomerular filtration rate was 33 mL/min/1.73 m². In total, 66% of patients were men, 81% had BP ≥ 130/80 mm Hg, and 75% were prescribed ≥2 antihypertensive drugs. During a median 5-year follow-up, the rate of changes of antihypertensive prescription was 50 per 100 person-years, 23 per 100 for add-ons, and 25 per 100 for withdrawals. After adjusting for risk factors, systolic BP, and the number of antihypertensive drugs, poor medication adherence was associated with increased HR for add-on (1.35, 95% confidence interval [CI], 1.01-1.80), whereas a lower education level was associated with increased HR for withdrawal (1.23, 95% CI, 1.02-1.49) for 9-11 years versus ≥12 years. More frequent nephrologist visits (≥4 vs none) were associated with higher HRs of add-on and withdrawal (1.52, 95% CI, 1.06-2.18; 1.57, 95% CI, 1.12-2.19, respectively), whereas associations with visit frequency to other physicians varied with their specialty. Mean systolic BP decreased by 4 mm Hg following drug add-on but tended to increase thereafter.
Lack of information on prescriber and drug dosing.
In patients with CKD and poor BP control, changes in antihypertensive drug prescriptions are common and relate to clinician preferences and patients' tolerability. Sustainable reduction in systolic BP after add-on of a drug class is infrequently achieved.
血压控制对于预防慢性肾脏病（CKD）的心肾并发症至关重要，但大多数患者未能达到血压目标。我们评估了抗高血压药物处方和收缩压的纵向模式。
前瞻性观察队列研究。
共有2755例3 - 4期CKD高血压患者，接受肾脏病专家的治疗，来自法国CKD - 肾脏流行病学和信息网络（CKD - REIN队列研究）。
患者因素，包括社会人口学特征、病史和实验室数据，以及医疗服务提供者因素，包括初级保健医生就诊次数和专科医生会诊次数。
随访期间抗高血压药物类别处方的变化：加用或停用。
采用分层共享脆弱模型估计风险比（HR）以处理肾脏病专家层面的聚类情况，并采用线性混合模型描述收缩压轨迹。
基线时，中位年龄为69岁，平均估算肾小球滤过率为33 mL/min/1.73 m²。总体而言，66%的患者为男性，81%的患者血压≥130/80 mmHg，75%的患者服用≥2种抗高血压药物。在中位5年的随访期间，抗高血压药物处方的变化率为每100人年50次，加用药物的变化率为每100人年23次，停用药物的变化率为每100人年25次。在调整了危险因素、收缩压和抗高血压药物数量后，药物依从性差与加用药物的HR增加相关（1.35，95%置信区间[CI]，1.01 - 1.80），而教育水平较低与9 - 11年（相对于≥12年）停用药物的HR增加相关（1.23，95% CI，1.02 - 1.49）。更频繁地拜访肾脏病专家（≥4次对比无）与加用和停用药物的HR更高相关（分别为1.52，95% CI，1.06 - 2.18；1.57，95% CI，1.12 - 2.19），而与拜访其他医生的频率的关联因其专业不同而有所变化。加用药物后平均收缩压下降了4 mmHg，但此后趋于上升。
缺乏关于开处方者和药物剂量的信息。
在血压控制不佳的CKD患者中，抗高血压药物处方的变化很常见，且与临床医生的偏好和患者的耐受性有关。加用一类药物后收缩压持续降低的情况很少见。
