title: Association of low blood pressure with increased mortality in patients with moderate to severe chronic kidney disease.
abstract: BACKGROUND
  Blood pressure shows an inverse association with mortality in patients with chronic kidney disease (CKD) on dialysis. It is unclear if the same phenomenon exists in patients with CKD not yet on dialysis.
  
  
  METHODS
  We examined the association of systolic (SBP) and diastolic (DBP) blood pressure with all-cause mortality in a historical prospective cohort of 860 patients (age 68.1+/-10.1 years, 99.1% male, 24.4% black) with estimated glomerular filtration rate (GFR) < 60 ml/min/1.73 m2. We used Cox models to adjust for the effects of age, race, diabetes mellitus, atherosclerotic cardiovascular disease (ASCVD), congestive heart failure, smoking, antihypertensive medications, body mass index, GFR, albumin, cholesterol, haemoglobin and proteinuria. To examine the role of comorbidities, we performed subgroup analyses based on prevalent ASCVD status and level of estimated GFR.
  
  
  RESULTS
  Higher SBP and higher DBP were both associated with lower mortality [adjusted hazard ratio (95% confidence interval) for SBP 133-154, 155-170 and > 170 mmHg, compared with < 133 mmHg, respectively: 0.61 (0.44-0.85), 0.62 (0.45-0.87) and 0.68 (0.49-0.96); and for DBP 65-75, 76-86 and > 86 mmHg, compared with < 65 mmHg: 0.85 (0.62-1.18), 0.72 (0.52-1.00) and 0.60 (0.41-0.86)]. The same association was present for both SBP and DBP only in subgroups with GFR < or = 30 ml/min/1.73 m2 and for DBP only in the subgroup with ASCVD.
  
  
  CONCLUSIONS
  Lower blood pressure is associated with higher mortality in patients with moderate to severe CKD, but interactions with kidney function and with ASCVD suggest that blood pressure may play a surrogate rather than a causative role in this association.
authors.affiliation: Division of Nephrology, Salem VA Medical Center, 1970 Roanoke Blvd, Salem, VA 24153, USA. csaba.kovesdy@med.va.gov
authors.forename: Csaba P
authors.initials: CP
authors.lastname: Kovesdy
authors.forename: Bhairvi K
authors.initials: BK
authors.lastname: Trivedi
authors.forename: Kamyar
authors.initials: K
authors.lastname: Kalantar-Zadeh
authors.forename: John E
authors.initials: JE
authors.lastname: Anderson
mesh_terms: D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D001795:Blood Pressure Determination; D002423:Cause of Death; D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007022:Hypotension / Q000175:diagnosis / Q000453:epidemiology*; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D007677:Kidney Function Tests; D008297:Male; D008875:Middle Aged; D011336:Probability; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D006435:Renal Dialysis; D018570:Risk Assessment; D012720:Severity of Illness Index; D017678:Sex Distribution; D016019:Survival Analysis