title: Impact of achieved blood pressures on mortality risk and end-stage renal disease among a large, diverse hypertension population.
abstract: BACKGROUND
  Medical data or clinical guidelines have not adequately addressed the ideal blood pressure (BP) treatment targets for survival and renal outcome.
  
  
  OBJECTIVE
  This study sought to evaluate ranges of treated BP in a large hypertension population and compare risk of mortality and end-stage renal disease (ESRD).
  
  
  METHODS
  A retrospective cohort study within the Kaiser Permanente Southern California health system was performed from January 1, 2006, to December 31, 2010. Treated hypertensive subjects ≥ 18 years of age were studied. Cox proportional hazards regression models were used to evaluate the risks (hazard ratios) for mortality and/or ESRD among different BP categories with and without stratification for diabetes mellitus and older age.
  
  
  RESULTS
  Among 398,419 treated hypertensive subjects (30% with diabetes mellitus), mortality occurred in 25,182 (6.3%) and ESRD in 4,957 (1.2%). Adjusted hazard ratios (95% confidence intervals [CI]) for composite mortality/ESRD in systolic BP <110, 110 to 119, 120 to 129, 140 to 149, 150 to 159, 160 to 169, and ≥ 170 compared with 130 to 139 mm Hg were 4.1 (95% CI: 3.8 to 1.3), 1.8 (95% CI: 1.7 to 1.9), 1.1 (95% CI: 1.1 to 1.1), 1.4 (95% CI: 1.4 to 1.5), 2.3 (95% CI: 2.2 to 2.5), 3.3 (95% CI: 3.0 to 3.6), and 4.9 (95% CI: 4.4 to 5.5) respectively. Diastolic BP 60 to 79 mm Hg were associated with the lowest risk. The nadir systolic and diastolic BP for the lowest risk was 137 and 71 mm Hg, respectively. Stratified analyses revealed that the diabetes mellitus population had a similar hazard ratio curve but a lower nadir at 131 and 69 mm Hg but age ≥ 70 had a higher nadir (140 and 70 mm Hg).
  
  
  CONCLUSIONS
  Both higher and lower treated BP compared with 130 to 139 mm Hg systolic and 60 to 79 mm Hg diastolic ranges had worsened outcomes. Our study adds to the growing uncertainty about BP treatment targets.
authors.affiliation: Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California. Electronic address: John.j.sim@kp.org.
authors.forename: John J
authors.initials: JJ
authors.lastname: Sim
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Jiaxiao
authors.initials: J
authors.lastname: Shi
authors.affiliation: Memphis VA Medical Center, Memphis, Tennessee.
authors.forename: Csaba P
authors.initials: CP
authors.lastname: Kovesdy
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California.
authors.forename: Kamyar
authors.initials: K
authors.lastname: Kalantar-Zadeh
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Jacobsen
mesh_terms: D000368:Aged; D001794:Blood Pressure / Q000502:physiology*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006973:Hypertension / Q000175:diagnosis* / Q000401:mortality* / Q000503:physiopathology; D007676:Kidney Failure, Chronic / Q000175:diagnosis* / Q000401:mortality* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance / Q000379:methods; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends
keywords: blood pressure goals; hypertension treatment; mortality risk; renal failure risk; treatment risk
references.citation: JAMA. 2000 Jul 26;284(4):465-71
references.pmid: 10904510
references.citation: Perm J. 2012 Summer;16(3):37-41
references.pmid: 23012597
references.citation: BMJ. 2008 May 17;336(7653):1121-3
references.pmid: 18480116
references.citation: N Engl J Med. 1996 Jan 4;334(1):13-8
references.pmid: 7494564
references.citation: Lancet. 2002 Dec 14;360(9349):1903-13
references.pmid: 12493255
references.citation: Can J Cardiol. 2014 May;30(5):544-52
references.pmid: 24786445
references.citation: JAMA. 2002 Nov 20;288(19):2421-31
references.pmid: 12435255
references.citation: Ann Intern Med. 2013 Aug 20;159(4):233-42
references.pmid: 24026256
references.citation: Hypertension. 2008 Nov;52(5):818-27
references.pmid: 18852389
references.citation: Hypertens Res. 2008 Dec;31(12):2115-27
references.pmid: 19139601
references.citation: Mayo Clin Proc. 2013 Oct;88(10):1099-107
references.pmid: 24079679
references.citation: N Engl J Med. 2010 Apr 29;362(17):1575-85
references.pmid: 20228401
references.citation: Lancet. 1997 Sep 13;350(9080):757-64
references.pmid: 9297994
references.citation: JAMA. 2010 Jul 7;304(1):61-8
references.pmid: 20606150
references.citation: JAMA. 2014 Feb 5;311(5):507-20
references.pmid: 24352797
references.citation: Lancet. 1998 Jun 13;351(9118):1755-62
references.pmid: 9635947
references.citation: Am J Hypertens. 2012 Mar;25(3):379-88
references.pmid: 22158065
references.citation: N Engl J Med. 2004 Sep 23;351(13):1296-305
references.pmid: 15385656
references.citation: Eur Heart J. 2010 Dec;31(23):2837-40
references.pmid: 20980328
references.citation: J Clin Hypertens (Greenwich). 2011 Mar;13(3):170-7
references.pmid: 21366848
references.citation: Lancet. 2005 Mar 12-18;365(9463):939-46
references.pmid: 15766995
references.citation: JAMA. 1991 Jun 26;265(24):3255-64
references.pmid: 2046107
references.citation: Lancet. 2006 Aug 19;368(9536):666-78
references.pmid: 16920472
references.citation: J Hum Hypertens. 2008 Oct;22(10):659-68
references.pmid: 18528409
references.citation: Hypertension. 2010 Aug;56(2):196-202
references.pmid: 20530299
references.citation: Lancet. 2004 Jun 19;363(9426):2022-31
references.pmid: 15207952
references.citation: JAMA. 2010 May 26;303(20):2043-50
references.pmid: 20501926
references.citation: Cochrane Database Syst Rev. 2012 Aug 15;(8):CD006742
references.pmid: 22895954
references.citation: J Gerontol A Biol Sci Med Sci. 2013 Sep;68(9):1059-67
references.pmid: 23666944
references.citation: Eur Heart J. 2010 Dec;31(23):2897-908
references.pmid: 20846991
references.citation: JAMA. 2002 Oct 16;288(15):1882-8
references.pmid: 12377087
references.citation: Ann Intern Med. 2009 May 5;150(9):604-12
references.pmid: 19414839
references.citation: Lancet. 2013 Aug 10;382(9891):507-15
references.pmid: 23726159
references.citation: N Engl J Med. 2008 Apr 10;358(15):1547-59
references.pmid: 18378520
references.citation: N Engl J Med. 2010 Sep 2;363(10):918-29
references.pmid: 20818902
references.citation: Lancet. 2000 Mar 11;355(9207):865-72
references.pmid: 10752701