Abstract
Hypertension frequently complicates chronic kidney disease (CKD), with studies showing clinical benefit from blood pressure lowering. Subgroups of patients with severe hypertension exist. We aimed to identify patients with the greatest mortality risk from uncontrolled hypertension to define the prevalence and phenotype of patients who might benefit from adjunctive therapies. 1691 all-cause CKD patients from the CRISIS study were grouped by baseline blood pressure—target (<140/80 mmHg); elevated (140–190/80–100 mmHg); extreme (>190 and/or 100 mmHg). Groups were well matched for age, eGFR, and comorbidities. 77 patients had extreme hypertension at recruitment but no increased mortality risk (HR 0.9, P = 0.9) over a median follow-up period of 4.5 years. The 1.2% of patients with extreme hypertension at recruitment and at 12-months had a significantly increased mortality risk (HR 4.3, P = 0.01). This association was not seen in patients with baseline extreme hypertension and improved 12-month blood pressures (HR 0.86, P = 0.5). Most CKD patients with extreme hypertension respond to pharmacological blood pressure control, reducing their risk for death. Patients with extreme hypertension in whom blood pressure control cannot be achieved have an approximate prevalence of 1%. These patients have an increased mortality risk and may be an appropriate group to consider for further therapies, including renal nerve ablation.
Highlights
The global epidemic of chronic kidney disease (CKD) represents a significant challenge for healthcare providers [1]
In comparison between all groups, baseline characteristics were well matched between all three blood pressure groups, with significant differences only observed in urinary protein to creatinine ratio, which increased with blood pressure group; hemoglobin, which increased (122 ± 16, 125 ± 17, 131 ± 19 g/L, P = 0.003); and history of myocardial infarction, which was inversely associated with increasing blood pressure (20%, 17%, 10%, P = 0.045)
We have demonstrated that only a small proportion of patients in a referred secondary care nephrology population, 20 (1.2%) in this analysis, has extreme elevations in blood pressure that persist despite specialist intervention
Summary
The global epidemic of chronic kidney disease (CKD) represents a significant challenge for healthcare providers [1]. Many therapeutic decisions are extrapolated from studies performed in the general population This may be inappropriate as many characteristics well recognized as risk factors for mortality in the general population exhibit reverse epidemiology in the CKD or dialysis population [2, 3]. Evidence of reduced mortality/cardiovascular events with “optimal” blood pressure management is even more limited [8, 9] This can be partly rationalized given that marked baseline hypertension appears to have only a modest effect on risk for death in predialysis CKD [10] and is often found to be a less important adverse prognostic marker than hypotension [11]. It may be that the important pathophysiological changes to the vasculature (and subsequent risk) associated with CKD relate more to vascular calcification than a blood pressure mediated process [12]
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