Of interest, the lack of predictive value of office BP measurement, as well as office BP target level, raises concerns regarding the adequacy of recommendations of hypertension guidelines that are derived mainly from expert opinion and post hoc analyses rather than randomized trials. Among the components of ABPM, nighttime systolic BP was a stronger predictor than daytime systolic BP for both end points, with an increased risk for the renal end point occurring for daytime SBP higher than mm Hg and an increased risk for the cardiovascular end point occurring for nighttime SBP higher than mm Hg.
The analysis with continuous variables confirmed the data obtained with the categorization of BP in quintiles. Interestingly, our data suggest that caution should be exercised with excessively low daytime SBP values because of the potential increase in cardiovascular risk Figure 2.
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The analysis of daytime and nighttime BP target levels provides another important finding of our study. International guidelines 1 - 3 , 35 do not provide specific thresholds for daytime and nighttime BP for patients with CKD. To determine whether achieving these goals implies a favorable risk factor profile or is causally associated with good outcomes will require randomized controlled trials.
Our results therefore suggest that the ABPM target levels recommended for patients with essential hypertension can be reasonably used in patients with CKD. This study also provides evidence that the lack of physiological BP decline during nighttime predicts important clinical outcomes in CKD, as described in a non-CKD population. Interestingly, this analysis also confirmed the poor predictive role of office BP measurement, as it was ineffective in discriminating risk profile across dipping categories.
Previous small, retrospective studies reported 41 - 44 the relationship between altered circadian pattern of BP and more rapid decline in renal function in specific subgroups of patients with CKD; however, none of these studies used important clinical end points such as ESRD, death, or cardiovascular events. More recently, Redon et al 45 evaluated the risk of renal death in a small number of patients with CKD stages 3 and 4. However, the population studied was scarcely representative of a typical CKD population because diabetic patients, those with previous cardiovascular disease, and those with more advanced CKD were excluded.
This selection bias led to an event rate in these patients much lower than that in the current study and in the cohort evaluated by Agarwal and Andersen, 28 therefore making the study by Redon et al somewhat underpowered. Only 1 study has investigated the effect of nondipping on cardiovascular outcome.
Analyzing a cohort of US veterans, Agarwal and Andersen 29 found that nondipping was associated with increased cardiovascular risk, but its predictive role disappeared after adjusting for other risk factors with the use of propensity scores. In contrast, our study found that an abnormal dipping pattern was a strong predictor of renal and cardiovascular outcomes, even after adjusting for the main demographic and clinical factors influencing dipping status.
The current study has some limitations. First, our study included few diabetic patients and was racially homogenous. A larger study with a more diverse population would allow generalization of our findings to patients with diabetes and nonwhite individuals. Second, ABPM data are based on a single set of measurements, which can lead to some imprecision, in particular, for dipping status. The third limitation relates to treatment of hypertension. The IDACO investigators demonstrated that use of antihypertensive drugs removed the significant association between cardiovascular events and daytime BP.
Finally, patients with true normotension were excluded, which may explain the difference with the IDACO study. The prediction of renal and cardiovascular risk among patients with CKD treated according to BP measured in physicians' offices was better with ABPM, in particular, nighttime BP and an abnormal dipping pattern. In contrast, office BP measurement was prognostically less informative. Interventional studies based on ABPM rather than office BP measurement are urgently required in this high-risk population.
Author Contributions: Dr Minutolo had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Statistical analysis : Agarwal, Borrelli, and Chiodini. Administrative, technical, and material support : Zamboli and De Nicola. All Rights Reserved. Figure 1. View Large Download. Table 1. Demographic and Clinical Characteristics of Patients.
The effect of a lower target blood pressure on the progression of kidney disease: long-term follow-up of the Modification of Diet in Renal Disease Study. Independent and additive impact of blood pressure control and angiotensin II receptor blockade on renal outcomes in the Irbesartan Diabetic Nephropathy Trial: clinical implications and limitations. Prevalence and clinical correlates of white coat hypertension in chronic kidney disease.
Effects of age on hypertensive status in patients with chronic kidney disease. Daytime and nighttime blood pressure as predictors of death and cause-specific cardiovascular events in hypertension. Changing the timing of antihypertensive therapy to reduce nocturnal blood pressure in CKD: an 8-week uncontrolled trial. Prediction of mortality by ambulatory blood pressure monitoring versus screening blood pressure measurements: a pilot study in Ohasama.
Prognostic value of ambulatory and home blood pressure compared with office blood pressure in the general population: follow-up results from the PAMELA study. Ambulatory blood pressure and year risk of cardiovascular and noncardiovascular mortality: the Ohasama study. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin Outcome Study.
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Chronic Kidney Disease and Hypertension: A Destructive Combination
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Purchase access Subscribe now. Purchase access Subscribe to JN Learning for one year. Sign in to customize your interests Sign in to your personal account. Hypertension was not defined any differently. Further, The geographical stratification of results revealed that developed areas such as Europe, USA, Canada and Australia had higher rates of CKD prevalence in comparison to areas where economies are growing such as sub Saharan Africa, India etc.
With the exception of Iran that had similar high level of CKD prevalence possibly due dietary risks, high BMI, high systolic BP and co-morbid conditions within the country [ ]. Although percentage prevalence was higher in more developed areas projected worldwide population changes will increase the absolute numbers of people in developing countries where the populations of elderly are increasing. This increase will exacerbate the double burden of dealing with communicable and non communicable disease in a developing economy[ ]. Serum creatinine measurement bias was inherent in the majority of the studies.
Not all countries have such guidelines only 5 manuscripts reported this in study design. Jaffe creatinine assay was the main method used but it is known to systematically overestimate serum creatinine to varying degrees. A comparison of these studies to the remainder found no significant difference in prevalence estimates. It is further known that the MDRD equation systematically overestimates CKD in the general population [ 13 ] and the prevalence rates calculated may be lower.
Estimated GFR is accepted as the most useful index of kidney function in health and disease, but an uncorrected, untraceable single measure inherently introduces noise and outliers into the dataset. However, the KDOQI guidelines that the included studies reference have stimulated controversies and questions. In particular, there have been concerns that use of its definition of CKD has caused excessive false identification of CKD and that its staging system was not sufficiently informative about prognosis.
A new KDIGO guideline was published in [ ] that sought to address this with the splitting of the stage 3 category to emphasise the risks of mortality and other outcomes vary greatly between these groups and have further and further sub-stratified by the inclusion of urinary albuminuria. One study may report an effect size adjusted for several possible confounders; others may report the crude prevalence.
The authors have sought to address this limitation by using STROBE quality weighting and creatinine quality factors and participant per study-weighted rates. Ideally future research should report the crude and adjusted rates based on multiple measures over time.
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This systematic review and meta-analysis significantly extends existing systematic reviews in a number of ways. The search strategy allowed the detection of a large number of additional studies that had not been considered in previous systematic reviews. It increased the number of reference databases searched. The reviewers undertook to screen non-English publications through the use of translations.
RENOPROTECTIVE EFFECT OF PERINDOPRIL IN PATIENTS WITH HYPERT : Journal of Hypertension
The studies included used the same definitions of CKD and used broadly comparable definitions for severity markers or related conditions albuminuria, hypertension, diabetes and obesity. However, there are limitations due to the heterogeneity that arises from differences in age and sex distributions, use of creatinine assays, different sampling frames, inclusion criteria of general population based studies, and time period of the study.
A proportion of the variation across studies may not be due to real differences in CKD prevalence. However, the authors did seek to provide a robust assessment of the quality and use this to determine a weighted global prevalence of CKD in the meta-analysis. The prevalence rates calculated highlight the likely numbers of people with CKD that may be of relevance to health care providers and national health programs with finite resources with which to address this epidemic. CKD constitutes a major cost burden to healthcare systems worldwide. The high prevalence and the extensive existing evidence that intervention is effective in reducing CVD events demonstrates a need for national initiatives that will slow the progression to end stage renal disease and reduce CVD-related events in CKD patients.
This comprehensive meta-analysis of observational studies confirms that CKD has a high prevalence. Evaluation of the roles of these interventions and the associated costs needs to be undertaken. CKD prevalence studies should report more detail on disease definitions and population demographics and state unadjusted as well as adjusted findings.
We wish to thank Ms.
Related Chronic Kidney Disease (CKD) and Hypertension Essentials 2011
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