Luca De Nicola1, Francis B Gabbai2, Rajiv Agarwal3, Paolo Chiodini4, Silvio Borrelli1, Vincenzo Bellizzi5, Felice Nappi6, Giuseppe Conte1, Roberto Minutolo7. 1. Department of Nephrology, Second University of Naples, Naples, Italy. 2. Department of Medicine, Veterans Administration San Diego Healthcare System and University of California at San Diego Medical School, San Diego, California. 3. Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana. 4. Medicine and Public Health, Second University of Naples, Naples, Italy. 5. Department of Nephrology, Salerno Hospital, Salerno, Italy. 6. Department of Nephrology, Nola Hospital, Nola, Italy. 7. Department of Nephrology, Second University of Naples, Naples, Italy. Electronic address: roberto.minutolo@unina2.it.
Abstract
OBJECTIVES: This study sought to evaluate in chronic kidney disease (CKD) prevalence and prognosis of true resistant hypertension (RH) (i.e., confirmed by ambulatory blood pressure [ABP] monitoring). BACKGROUND: In CKD, uncontrolled hypertension is a major risk factor, but no study has properly investigated the role of RH. METHODS: We prospectively studied 436 hypertensive CKD patients under nephrology care. Four groups were constituted by combining 24-h ABP with diagnosis of RH (office blood pressure ≥130/80 mm Hg, despite adherence to ≥3 full-dose antihypertensive drugs including a diuretic agent or ≥4 drugs): control (ABP <125/75 mm Hg without RH); pseudoresistance (ABP <125/75 mm Hg with RH); sustained hypertension (ABP ≥125/75 mm Hg without RH); and true resistance (ABP ≥125/75 mm Hg with RH). Endpoints of survival analysis were renal (end-stage renal disease or death) and cardiovascular events (fatal and nonfatal cardiovascular event). RESULTS: Age was 65 ± 14 years, men 58%, diabetes 36%, cardiovascular disease 30%, median proteinuria 0.24 (interquartile range 0.09 to 0.83) g/day, estimated glomerular filtration rate 43 ± 20 ml/min/1.73 m(2), office blood pressure 146 ± 19/82 ± 12 mm Hg, and 24-h ABP 129 ± 17/72 ± 10 mm Hg. True resistant patients were 22.9%, and pseudoresistant patients were 7.1%, whereas patients with sustained hypertension were 42.9%, and control subjects were 27.1%. Over 57 months of follow-up, 109 cardiovascular events and 165 renal events occurred. Cardiovascular risk (hazard ratio [95% confidence interval]) was 1.24 (0.55 to 2.78) in pseudoresistance, 1.11 (0.67 to 1.84) in sustained hypertension, and 1.98 (1.14 to 3.43) in true resistance, compared with control subjects. Corresponding hazards for renal events were 1.18 (0.45 to 3.13), 2.14 (1.35 to 3.40), and 2.66 (1.62 to 4.37). CONCLUSIONS: In CKD, pseudoresistance is not associated with an increased cardio-renal risk, and sustained hypertension predicts only renal outcome. True resistance is prevalent and identifies patients carrying the highest cardiovascular risk.
OBJECTIVES: This study sought to evaluate in chronic kidney disease (CKD) prevalence and prognosis of true resistant hypertension (RH) (i.e., confirmed by ambulatory blood pressure [ABP] monitoring). BACKGROUND: In CKD, uncontrolled hypertension is a major risk factor, but no study has properly investigated the role of RH. METHODS: We prospectively studied 436 hypertensiveCKDpatients under nephrology care. Four groups were constituted by combining 24-h ABP with diagnosis of RH (office blood pressure ≥130/80 mm Hg, despite adherence to ≥3 full-dose antihypertensive drugs including a diuretic agent or ≥4 drugs): control (ABP <125/75 mm Hg without RH); pseudoresistance (ABP <125/75 mm Hg with RH); sustained hypertension (ABP ≥125/75 mm Hg without RH); and true resistance (ABP ≥125/75 mm Hg with RH). Endpoints of survival analysis were renal (end-stage renal disease or death) and cardiovascular events (fatal and nonfatal cardiovascular event). RESULTS: Age was 65 ± 14 years, men 58%, diabetes 36%, cardiovascular disease 30%, median proteinuria 0.24 (interquartile range 0.09 to 0.83) g/day, estimated glomerular filtration rate 43 ± 20 ml/min/1.73 m(2), office blood pressure 146 ± 19/82 ± 12 mm Hg, and 24-h ABP 129 ± 17/72 ± 10 mm Hg. True resistant patients were 22.9%, and pseudoresistant patients were 7.1%, whereas patients with sustained hypertension were 42.9%, and control subjects were 27.1%. Over 57 months of follow-up, 109 cardiovascular events and 165 renal events occurred. Cardiovascular risk (hazard ratio [95% confidence interval]) was 1.24 (0.55 to 2.78) in pseudoresistance, 1.11 (0.67 to 1.84) in sustained hypertension, and 1.98 (1.14 to 3.43) in true resistance, compared with control subjects. Corresponding hazards for renal events were 1.18 (0.45 to 3.13), 2.14 (1.35 to 3.40), and 2.66 (1.62 to 4.37). CONCLUSIONS: In CKD, pseudoresistance is not associated with an increased cardio-renal risk, and sustained hypertension predicts only renal outcome. True resistance is prevalent and identifies patients carrying the highest cardiovascular risk.
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