The association of nocturnal hypertension and nondipping blood pressure with treatment‐resistant hypertension: The Jackson Heart Study

Apparent treatment‐resistant hypertension (aTRH), nocturnal hypertension, and nondipping blood pressure (BP) have shared risk factors. The authors studied the association between aTRH and nocturnal hypertension and aTRH and nondipping BP among 524 black Jackson Heart Study participants treated for hypertension. Nocturnal hypertension was defined by mean nighttime systolic BP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping BP was defined by mean nighttime to daytime systolic BP ratio >0.90. aTRH was defined by mean clinic systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg with three medication classes or treatment with four or more classes. The risk for developing aTRH associated with nondipping BP and nocturnal hypertension was estimated. After multivariable adjustment, participants with aTRH were more likely to have nocturnal hypertension (prevalence ratio, 1.20; 95% confidence interval, 1.03–1.39) and nondipping (prevalence ratio, 1.25; 95% confidence interval, 1.09–1.43). Over a median 7.3 years of follow‐up, nocturnal hypertension and nondipping BP at baseline were not associated with developing aTRH after adjustment.     

White‐coat and masked hypertension diagnoses in chronic kidney disease patients

The purpose of this study was to analyze which 24‐hour ambulatory blood pressure measurement (ABPM) parameters should be used on masked hypertension (MH) and white‐coat hypertension (WCH) diagnoses in chronic kidney disease (CKD) patients. Non‐dialysis CKD patients underwent 24‐hour ABPM examination between 01/27/2004 and 02/16/2012. They were followed from the 24‐hour ABPM to January/2014 in an observational study. The WCH definitions tested were as follows: (a) office blood pressure (BP) ≥ 140/90 mm Hg and daytime ABPM BP ≤ 135/85 mm Hg (old criterion); and (b) office BP ≥ 140/90 mm Hg and 24‐hour ABPM BP ≤ 130/80 mm Hg, daytime ABPM BP ≤ 135/85 mm Hg, and nighttime ABPM BP ≤ 120/70 mm Hg (new criterion). The MH definitions tested were as follows: (a) office BP < 140/90 mm Hg and daytime ABPM BP > 135/85 mm Hg (old criterion); and (b) office BP < 140/90 mm Hg and 24‐hour ABPM BP > 130/80 mm Hg or daytime ABPM BP > 135/85 mm Hg or nighttime ABPM BP > 120/70 mm Hg (new criterion). The two definitions' predictive capacity was compared, regarding both WCH and MH. Cardiovascular mortality was the primary and all‐cause mortality was the secondary outcome. Cox regression was adjusted to the variables: glomerular filtration rate, age, diabetes mellitus, and active smoking. There were 367 patients studied. The old criterion (exclusive mean daytime ABPM BP) was the only to distinguish sustained hypertension from WCH (adjusted HR: 3.730; 95% CI: 1.068‐13.029; P = .039), regarding all‐cause mortality. Additionally, the old criterion was the only one to distinguish normotension and MH, regarding cardiovascular mortality (adjusted HR: 7.641; 95% CI: 1.277‐45.738; P = .026). Therefore, WCH and MH definitions based exclusively on daytime ABPM BP values (old criterion) were able to better distinguish mortality in this studied CKD cohort.     

Prevalence and prognosis of the 2018 vs 2008 AHA definitions of apparent treatment‐resistant hypertension in high‐risk hypertension patients

Resistant hypertension was defined according to the 2008 scientific statement as office blood pressure ≥ 140/90 mm Hg and the 2018 scientific statement as office blood pressure ≥ 130/80 mm Hg. We investigated the prognostic significance of lowered blood pressure threshold for defining resistant hypertension in the 2018 American Heart Association scientific statement compared with that in the 2008 scientific statement. The participants of this prospective cohort were enrolled from December 2013 to November 2018. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiovascular death, non‐fatal myocardial infarction, non‐fatal stroke, and heart failure hospitalization. Renal event was defined as a ≥ 50% decline in estimated glomerular filtration rate or progression to end‐stage renal disease. A total of 206 patients among 2018 (10.2%) were diagnosed with resistant hypertension by the previous definition (≥140/90 mm Hg), and 276 patients among 2011 (13.7%) were diagnosed with resistant hypertension by the updated definition (≥130/80 mm Hg). During a median follow‐up of 4.5 years, 33 MACEs (3.7 per 1000 patient‐years) and 164 renal events (19.9 per 1000 patient‐years) occurred in the study population. Treatment‐resistant hypertension groups had a higher incidence rate of MACEs and renal events than the control groups. In multivariate Cox proportional hazards regression analysis, resistant hypertension by both definitions was significantly associated with increased risk of MACE and renal event. Both the previous and updated definitions of resistant hypertension were significant predictors of MACEs and renal events. This finding supports the adoption of the updated criteria for resistant hypertension in clinical practice.     

Resistant and undertreated hypertension in patients with chronic kidney disease: data from the PATRIOTIC survey

ABSTRACT

Background: Hypertension is prevalent in chronic kidney disease (CKD), but the control of hypertension is suboptimal. We reported the prevalence and characteristics of resistant and undertreated hypertension based on a nationwide survey aiming to improve blood pressure (BP) control. Methods: Resistant hypertension (RH) was defined as BP above the target (<140/90 mm Hg) despite the use of 3 antihypertensive drugs or achieving the target BP by using ≥4 antihypertensive drugs. Undertreated hypertension was defined as uncontrolled hypertension (unCH) using ≤2 drugs. We compared the characteristics and antihypertensive treatment among different groups (including RH and unCH using ≤2 drugs). Multivariable logistic regression was used to detect factors associated with unCH using ≤2 drugs and RH. Results: 4,435 nondialysis CKD patients with hypertension were analyzed, and 36.9% of participants achieved controlled hypertension (CH) using ≤3 drugs, 11.1% met the criteria for RH, and 52% had unCH despite the use of ≤ 2 antihypertensive drugs. Participants with unCH using ≤ 2 drugs had low usage of renin-angiotensin system blockers (36.8%) and diuretics (5.5%), which was much lower than participants with CH using ≤3 drugs and RH (P< 0.05). After multivariable adjustment, obesity, advanced CKD stages, urinary protein level of ≥1.5 g/24 h, diabetes, and cardiovascular disease were associated with RH in CKD patients (P< 0.05). Conclusion: Compared with RH, undertreated hypertension contributes more to the unCH in Chinese CKD patients. It is important to ensure adequate antihypertensive treatment, including choosing antihypertensive drugs, that guidelines recommended.     

Catheter‐based renal denervation in Chinese patients with chronic kidney disease and uncontrolled hypertension

Sympathetic activation contributes to the progression of hypertension and chronic kidney disease (CKD). Ablation of renal sympathetic nerves lowers blood pressure (BP) and preserves renal function in patients with CKD and uncontrolled hypertension by reducing sympathetic nerve activity. But whether this approach is safe and effective in Chinese patients with CKD is unknown. We performed an observational study of eight patients with CKD stages from 1 to 5, office BP ≥150/90 mmHg, while on at least three antihypertensive drug classes including a diuretic, and diagnosis confirmed by 24 h ambulatory systolic BP measurement ≥135 mmHg. All patients underwent catheter‐based renal denervation (RDN) using a newly designed RDN System (Golden Leaf Medtech, Shanghai, China). For up to 6 months after RDN, BP was monitored and renal function was assessed. Mean baseline office BP was 165.0 ± 13.9/97.8 ± 5.5 mmHg, despite treatment with three antihypertensive drugs. Six months after RDN, office BP was reduced by 22.1 ± 12.0 (P = .002)/11.0 ± 8.8 mmHg (P = .012) and average 24 h ambulatory BP by 18 ± 13.7 (P = .01)/9.3 ± 7.7 mmHg (P = .016). After RDN, heart rate and estimated glomerular filtration rate (GFR) had no significant change compared with before RDN. In Chinese patients with CKD, our observational pilot study found that treating hypertension with RDN lowers BP while not affecting renal function.Brief Abstract: We performed RDN in eight Chinese patients with hypertension and CKD. The results showed that RDN lowered blood pressure of these patients significantly and eGFR was stable. No obvious adverse event was observed.     

Clinical characteristics of resistant hypertension evaluated by ambulatory blood pressure monitoring

Strict control of blood pressure is important to prevent cardiovascular disease, although it is sometimes difficult to decrease blood pressure to target levels. The aim of this study was to investigate the clinical characteristics of resistant hypertension evaluated by ambulatory blood pressure monitoring. One hundred in-hospital patients, whose 24-hour average blood pressure was higher than 130/80?mmHg even after treatment with more than three antihypertensive drugs, were included in the present analysis. Circadian variation of blood pressure was evaluated by nocturnal fall in systolic blood pressure. Average blood pressures of all patients were high in both daytime and nighttime, 150.0/82.9 and 143.8/78.2?mmHg, respectively. Twenty patients had been treated with hemodialysis or peritoneal dialysis. In 63 patients out of the other 80 patients (79%), estimated glomerular filtration rate (eGFR) was also decreased (<60?mL/min/1.73 m²). The patients classified into dipper, non-dipper, riser and extreme-dipper were 20%, 43%, 34% and 3%, respectively. In addition, in 17 patients whose eGFR was preserved, 12 patients showed a non-dipper or riser pattern, suggesting that it was difficult to account for this altered circadian blood pressure variation only by renal dysfunction. These results show that a large number of the patients with resistant hypertension suffered from renal dysfunction, although it was difficult to explain altered circadian blood pressure variation based on renal dysfunction alone.     

夜间高血压监测对慢性肾脏病的临床意义

慢性肾脏病(CKD,chronic kidney disease)是全球性的健康问题,且发病率日益增长,中国CKD3~5期患病率已达10.5%~11.8%[1-2]。高血压既是引起CKD的病因,也是CKD导致的主要并发症之一。肾功能正常或近正常的CKD患者高血压患病率65%,而终末期肾病(end stage renal disease,ESRD)高血压患病率升高至95%[3]。2012年,高血压已成为美国ESRD的第二大主要原因(34%),仅次于糖尿病。肾小球滤过率的降低与高血压患病率和血压控制达标比例有关[4]。     

Catheter-based renal denervation in Chinese patients with chronic kidney disease and uncontrolled hypertension

Sympathetic activation contributes to the progression of hypertension and chronic kidney disease (CKD). Ablation of renal sympathetic nerves lowers blood pressure (BP) and preserves renal function in patients with CKD and uncontrolled hypertension by reducing sympathetic nerve activity. But whether this approach is safe and effective in Chinese patients with CKD is unknown. We performed an observational study of eight patients with CKD stages from 1 to 5, office BP ≥150/90 mmHg, while on at least three antihypertensive drug classes including a diuretic, and diagnosis confirmed by 24 h ambulatory systolic BP measurement ≥135 mmHg. All patients underwent catheter-based renal denervation (RDN) using a newly designed RDN System (Golden Leaf Medtech, Shanghai, China). For up to 6 months after RDN, BP was monitored and renal function was assessed. Mean baseline office BP was 165.0 ± 13.9/97.8 ± 5.5 mmHg, despite treatment with three antihypertensive drugs. Six months after RDN, office BP was reduced by 22.1 ± 12.0 (P = .002)/11.0 ± 8.8 mmHg (P = .012) and average 24 h ambulatory BP by 18 ± 13.7 (P = .01)/9.3 ± 7.7 mmHg (P = .016). After RDN, heart rate and estimated glomerular filtration rate (GFR) had no significant change compared with before RDN. In Chinese patients with CKD, our observational pilot study found that treating hypertension with RDN lowers BP while not affecting renal function. Brief Abstract: We performed RDN in eight Chinese patients with hypertension and CKD. The results showed that RDN lowered blood pressure of these patients significantly and eGFR was stable. No obvious adverse event was observed.     

Effect of chronic kidney disease on the association between hyperuricemia and new‐onset hypertension in the general Japanese population: ISSA‐CKD study

We aimed to investigate the association between serum uric acid (SUA) level and development of hypertension as well as the interaction effect of chronic kidney disease (CKD) on this relationship in the general Japanese population. We included 7895 participants aged ≥30 years from the ISSA‐CKD study, a population‐based retrospective cohort study that used annual health check‐up data of residents from Iki Island, Japan. After the exclusion of 1881 with l < 1‐year follow‐up, 2812 with hypertension at baseline, and 165 with missing information on SUA, a total of 3037 participants were enrolled in this analysis. Participants were divided into four groups according to the quartiles of SUA level at baseline, and multivariable‐adjusted hazard ratios for new‐onset hypertension were calculated. Stratified analyses were performed for each subgroup (defined by sex, age, alcohol intake, and CKD) to assess the interaction effects. During a mean follow‐up period of 4.4 years, 943 participants developed hypertension. The first quartile group was set as the reference group, and the multivariable‐adjusted hazard ratios (95% confidence interval) for new‐onset hypertension were 1.11 (0.90–1.36) in the second quartile, 1.25 (1.02–1.54) in the third quartile, and 1.35 (1.07–1.70) in the fourth quartile compared with those in the reference group (p = .007 for trend). The stratified analyses showed that the association between SUA and hypertension was significantly stronger in participants with CKD than in those without CKD (p = .035 for interaction). SUA level is an independent risk factor for new‐onset hypertension. This tendency was significantly stronger in participants with CKD.     

3～4期慢性肾脏病合并高血压265例用药控制情况及影响因素分析

目的了解慢性肾脏病(CKD)3～4期合并高血压患者血压控制情况、治疗现状,分析其影响因素。方法分析2010年4月至2011年4月265例在北京友谊医院CKD门诊规律随访3个月以上的CKD 3～4期合并高血压的患者的临床资料和治疗情况。结果高血压知晓率为97.7%,知道正确靶目标值的患者占83%,血压控制在130/80 mmHg以下的CKD高血压患者占39.2%。服用3种以上降压药物的患者占19.6%,利尿剂使用比例6.8%。结论应加强对CKD合并高血压患者的教育及自我管理的培训,临床医师应给予患者更加积极合理的降压治疗,提高血压控制率,改善预后。     

Prevalence and predictors of chronic kidney disease among Ghanaian patients with hypertension and diabetes mellitus: A multicenter cross‐sectional study

The burden of chronic kidney disease (CKD) is rapidly rising in developing countries due to astronomical increases in key risk factors including hypertension and diabetes. We sought to assess the burden and predictors of CKD among Ghanaians with hypertension and/or diabetes mellitus in a multicenter hospital‐based study. We conducted a cross‐sectional study in the Ghana Access and Affordability Program (GAAP) involving adults with hypertension only (HPT), hypertension with diabetes mellitus (HPT + DM), and diabetes mellitus only (DM) in 5 health facilities in Ghana. A structured questionnaire was administered to collect data on demographic variables, medical history, and clinical examination. Serum creatinine and proteinuria were measured, and estimated glomerular filtration rate derived using the CKD‐EPI formula. A multivariable logistic regression model was used to identify factors associated with CKD. A total of 2781 (84.4%) of 3294 participants had serum creatinine and proteinuria data available for analysis. The prevalence of CKD was 242 (28.5%) among participants with both DM and HPT, 417 (26.3%) among participants with HPT, and 56 (16.1%) among those with DM alone. Predictors of CKD were increasing age aOR 1.26 (1.17‐1.36), low educational level aOR 1.7 (1.23‐2.35), duration of HPT OR, 1.02 (1.01‐1.04), and use of herbal medications aOR 1.39 (1.10‐1.75). Female gender was protective of CKD aOR 0.75 (0.62‐0.92). Among patients with DM, increasing age and systolic blood pressure were associated with CKD. There is high prevalence of CKD among DM and hypertension patients in Ghana. Optimizing blood pressure control and limiting the use of herbal preparations may mitigate CKD occurrence in high cardiovascular risk populations in developing countries.     

Current apparent treatment‐resistant hypertension in patients undergoing peritoneal dialysis: A multi‐center cross‐sectional study

Apparent treatment‐resistant hypertension (aTRH) is the most commonly used term to report resistant hypertension (RH) and is considered as a common problem in dialysis population. However, few reports have focused on peritoneal dialysis (PD) hypertensive patients. The authors conducted a multi‐center cross‐sectional study involving 1789 PD patients from nine centers in Guangdong, China. The prevalence of aTRH was estimated by home blood pressure (BP) monitoring. Evaluating drug adherence through Eight‐item Morisky Medication Adherence Scale (MMAS‐8) and pill counting was performed to assess RH in one PD center. Related factors of aTRH were analyzed using logistic regression analysis. The prevalence of aTRH in PD patients was estimated at 42.2% (755 out of 1789 hypertensive patients) based on home BP. Of those, 91.4% patients were classified as uncontrolled RH, 2.0% as controlled RH, and 6.6% as refractory hypertension. The prevalence of RH was 40.6% and 41.9% among those with medium/high adherence based on the MMAS‐8 scores and the pill counting rate, respectively. PD patients who were younger, with higher body mass index, with lower serum albumin and poorer dialysis adequacy were significantly associated with higher aTRH incident. In conclusion, the present study demonstrates a high prevalence of aTRH in PD population, which occurs in about two in five treated hypertensive patients. Nutritional status and dialysis adequacy might tightly associate with aTRH.     

The effects of hypertension and diabetes on new‐onset chronic kidney disease: A prospective cohort study

The study aimed to determine the different status of hypertension and diabetes on the risk of new‐onset chronic kidney disease (CKD) events in Kailuan Study. A total of 21 905 individuals were enrolled in the study. The new‐onset incidents of CKD, hypertension, and diabetes were collected in the follow‐ups. All the individuals were divided into five groups according to baseline and follow‐up hypertension and diabetes status: baseline hypertension (BH), baseline hypertension and incidence of diabetes (BHID), baseline diabetes (BD), baseline diabetes and incidence of hypertension (BDIH), and baseline hypertension and diabetes (BHD). The risk of new‐onset CKD of the five groups was calculated using the Cox regression analysis. In the median follow‐up of 7.05 ± 2.59 years, the prevalence of new‐onset CKD in the group of BH, BHID, BD, BDIH, and BHD were 27.1, 43.79, 25.4, 36.6, and 45.1 per 1000 years, respectively. When adjusted possible confounders, the hazard ratios (HRs) and 95% confidence intervals (CIs) of new‐onset CKD were 1.50 (95% CI: 1.38‐1.63), 1.25(95% CI: 1.07‐1.47), and 1.52 (95% CI: 1.35‐1.7) in the group of BHID, BDIH, and BHD, respectively, as referred to the BH group (P < .001). No obvious difference was observed in the group of BH and BD for the incidence of new‐onset CKD. Sensitivity analysis still showed the similar results among the five groups. The study showed that the effect of simple hypertension or simple diabetes on new‐onset CKD was not significantly different, but the incidence of new‐onset hypertension or diabetes increased the risk of new‐onset CKD. Hypertension and diabetes had a synergistic influence on the risk of new‐onset CKD.     

Primary prevention of chronic kidney disease through population‐based strategies for blood pressure control: The ARIC study

While much of the chronic kidney disease (CKD) literature focuses on the role of blood pressure reduction in delaying CKD progression, little is known about the benefits of modest population‐wide decrements in blood pressure on incident CKD. The authors used multivariable linear regression to characterize the impact on incident CKD of two approaches for blood pressure management: (1) a 1‐mm Hg reduction in systolic BP across the entire study population; and (2) a 10% reduction in participants with unaware, untreated, and uncontrolled BP above goal as defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) thresholds. Over a mean of 20 years of follow‐up (ARIC [Atherosclerosis Risk in Communities] study, n = 15 390), 3852 incident CKD events were ascertained. After adjustment, a 1‐mm Hg decrement in systolic BP across the population was associated with an estimated 11.7 (95% confidence interval [CI], 6.2–17.3) and 13.4 (95% CI, 10.3–16.6) fewer CKD events per 100 000 person‐years in blacks and whites, respectively. Among participants with BP above JNC 7 goal, a 10% decrease in unaware, untreated, or uncontrolled BP was associated with 3.2 (95% CI, 2.0–4.9), 2.8 (95% CI, 1.8–4.3), and 5.8 (95% CI, 3.6–8.8) fewer CKD events per 100 000 person‐years in blacks and 3.1 (95% CI, 2.3–4.1), 0.7 (95% CI, 0.5–0.9), and 1.0 (95% CI, 1.3–2.4) fewer CKD events per 100 000 person‐years in whites. Modest population‐wide reductions in systolic BP hold potential for the primary prevention of CKD.     

Utilization of antihypertensive drugs among chronic kidney disease patients: Results from the Chinese cohort study of chronic kidney disease (C‐STRIDE)

The utilization of antihypertensive drugs plays an important role in blood pressure control among chronic kidney disease (CKD) patients. Limited information was available on how antihypertensive drugs were used among Chinese CKD patients. In the present study, the utilization of antihypertensive drugs among a subgroup of hypertensive participants with a complete record of antihypertensive drug information from the Chinese Cohort Study of Chronic Kidney Disease was analyzed. Among 2213 subjects, 61.7% and 26.5% had their blood pressure controlled to <140/90 mmHg and <130/80 mmHg, respectively. In total, 38.5% were on monotherapy. Of those patients who received combination therapy, 57.8% were treated with a two‐drug combination. Renin‐angiotensin system inhibitors (RASIs) were the most commonly prescribed drugs (71.2%). Only 10.2% of the patients were prescribed diuretics. After multivariable adjustment, participants taking RASI were more likely to have their blood pressure controlled to <140/90 mmHg (prevalence ratio (PR) 1.153, 95% confidence interval (CI): 1.071‐1.240). CKD stage 4 (PR 0.548, 95% CI: 0.434‐0.692) was associated with RASIs treatment. Additionally, diabetes (PR 1.498, 95% CI: 1.120‐2.004), albumin/creatinine ratio ≥300 mg/g (PR 1.547, 95% CI: 1.020‐2.344), and CKD stage 4 (PR 2.022, 95% CI: 1.223‐3.343) were associated with diuretic use. The results suggested that combination therapy, diuretics use in general, and utilization of RASIs in advanced CKD stage were insufficient in the current treatment of Chinese hypertensive CKD patients.