title: Blood pressure and pulse pressure effects on renal outcomes in the Veterans Affairs Diabetes Trial (VADT).
abstract: OBJECTIVE
  Blood pressure (BP) control for renal protection is essential for patients with type 2 diabetes. Our objective in this analysis of Veterans Affairs Diabetes Trial (VADT) data was to learn whether on-study systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) affected renal outcomes measured as albumin-to-creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR).
  
  
  METHODS
  The VADT was a prospective, randomized study of 1,791 veterans with type 2 diabetes to determine whether intensive glucose control prevented major cardiovascular events. In this post hoc study, time-varying covariate survival analyses and hazard ratios (HR) were used to determine worsening of renal outcomes.
  
  
  RESULTS
  Compared with SBP 105-129 mmHg, the risk of ACR worsening increased significantly for SBP 130-139 mmHg (HR 1.88 [95% CI 1.28-2.77]; P = 0.001) and for SBP ≥140 mmHg (2.51 [1.66-3.78]; P < 0.0001). Compared with a PP range of 40-49 mmHg, PP <40 was associated with significantly lowered risk of worsening ACR (0.36 [0.15-0.87]; P = 0.022) and PP ≥60 with significantly increased risk (2.38 [1.58-3.59]; P < 0.0001). Analyses of BP ranges associated with eGFR worsening showed significantly increased risk with rising baseline SBP and an interaction effect between SBP ≥140 mmHg and on-study A1C. These patients were 15% more likely than those with SBP <140 mmHg to experience eGFR worsening (1.15 [1.00-1.32]; P = 0.045) for each 1% (10.9 mmol/mol) A1C increase.
  
  
  CONCLUSIONS
  SBP ≥130 mmHg and PP >60 mmHg were associated with worsening ACR. The results suggest that treatment of SBP to <130 mmHg may lessen ACR worsening. The interaction between SBP ≥140 mmHg and A1C suggests that the effect of glycemic control on reducing progression of renal disease may be greater in hypertensive patients.
authors.affiliation: Endocrinology, Veterans Affairs Medical Center, Omaha, NE robert.anderson4@va.gov.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Anderson
authors.affiliation: Cooperative Studies Program Coordinating Center, Hines Veterans Affairs Hospital, Hines, IL.
authors.forename: Gideon D
authors.initials: GD
authors.lastname: Bahn
authors.affiliation: Research and Medical Services, Hines Veterans Affairs Hospital, Hines, IL.
authors.forename: Nicholas V
authors.initials: NV
authors.lastname: Emanuele
authors.affiliation: Medical Service, Endocrinology Section, Veterans Affairs Medical Center, Miami, FL.
authors.forename: Jennifer B
authors.initials: JB
authors.lastname: Marks
authors.affiliation: Research Service, Veterans Affairs Medical Center, Phoenix, AZ.
authors.forename: William C
authors.initials: WC
authors.lastname: Duckworth
mesh_terms: D000368:Aged; D001794:Blood Pressure / Q000187:drug effects; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology* / Q000628:therapy; D003928:Diabetic Nephropathies / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D018450:Disease Progression; D005260:Female; D006801:Humans; D006973:Hypertension / Q000503:physiopathology; D007668:Kidney / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D016896:Treatment Outcome; D014728:Veterans