title: Visit-to-visit variability in blood pressure and kidney and cardiovascular outcomes in patients with type 2 diabetes and nephropathy: a post hoc analysis from the RENAAL study and the Irbesartan Diabetic Nephropathy Trial.
abstract: BACKGROUND
  Increased systolic blood pressure variability between outpatient visits is associated with increased incidence of cardiovascular end points. However, few studies have examined the association of visit-to-visit variability in systolic blood pressure with clinically relevant kidney disease outcomes. We analyzed the association of systolic blood pressure visit-to-visit variability with renal and cardiovascular morbidity and mortality among individuals with diabetes and nephropathy.
  
  
  METHODS
  Observational analysis of IDNT (Irbesartan Diabetic Nephropathy Trial) and the RENAAL (Reduction of End Points in Non-Insulin-Dependent Diabetes With the Angiotensin II Antagonist Losartan) Study.
  
  
  METHODS
  2,739 participants with type 2 diabetes and nephropathy with at least 1 year of blood pressure measurements available.
  
  
  METHODS
  Systolic blood pressure visit-to-visit variability was calculated from the SD of the systolic blood pressure from 4 visits occurring 3-12 months postrandomization.
  
  
  RESULTS
  The kidney disease outcome was defined as time to confirmed doubling of serum creatinine level, end-stage renal disease, or death; the cardiovascular outcome was defined as time to cardiovascular death, myocardial infarction, stroke, hospitalization for heart failure, or revascularization.
  
  
  RESULTS
  Mean visit-to-visit variability in systolic blood pressure from 3 to 12 months postrandomization was 12.0±6.8(SD)mmHg. Following this ascertainment period, there were 954 kidney disease and 542 cardiovascular events. Greater systolic blood pressure visit-to-visit variability was associated independently with increased risk of the composite kidney disease end point (HR per 1-SD increment, 1.08 [95%CI, 1.01-1.16]; P=0.02) and end-stage renal disease, but not with the cardiovascular outcome.
  
  
  CONCLUSIONS
  Observational study with the potential for confounding.
  
  
  CONCLUSIONS
  In diabetic individuals with nephropathy, systolic blood pressure visit-to-visit variability is associated independently with hard kidney disease outcomes.
authors: Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
authors: Ciaran J
authors: CJ
authors: McMullan
authors: Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
authors: Hiddo J
authors: HJ
authors: Lambers Heerspink
authors: Department of Medical Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Faculty of Health Science, University of Aarhus, Aarhus, Denmark.
authors: Hans-Henrik
authors: HH
authors: Parving
authors: Division of Nephrology, VanderBilt University, Nashville, TN.
authors: Jamie P
authors: JP
authors: Dwyer
authors: Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA. Electronic address: jforman@partners.org.
authors: John P
authors: JP
authors: Forman
authors: Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. Electronic address: d.de.zeeuw@umcg.nl.
authors: Dick
authors: D
authors: de Zeeuw
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D047228:Angiotensin II Type 1 Receptor Blockers / Q000494:pharmacology / Q000627:therapeutic use; D001713:Biphenyl Compounds / Q000494:pharmacology / Q000627:therapeutic use; D001794:Blood Pressure / Q000187:drug effects / Q000502:physiology; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000188:drug therapy / Q000503:physiopathology; D015331:Cohort Studies; D003924:Diabetes Mellitus, Type 2 / Q000175:diagnosis / Q000188:drug therapy / Q000503:physiopathology; D003928:Diabetic Nephropathies / Q000175:diagnosis / Q000188:drug therapy / Q000503:physiopathology; D004311:Double-Blind Method; D005500:Follow-Up Studies; D000077405:Irbesartan; D007668:Kidney / Q000187:drug effects / Q000502:physiology; D009819:Office Visits / Q000639:trends; D011446:Prospective Studies; D013777:Tetrazoles / Q000494:pharmacology / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D047228:Angiotensin II Type 1 Receptor Blockers; D001713:Biphenyl Compounds; D000077405:Irbesartan; D013777:Tetrazoles
keywords: Reduction of End Points in Non–Insulin-Dependent Diabetes With the Angiotensin II Antagonist Losartan (RENAAL); Visit-to-visit variability in blood pressure; diabetic kidney disease; kidney disease outcomes; systolic blood pressure (SBP)