title: Reassessment of Ambulatory Blood Pressure Improves Renal Risk Stratification in Nondialysis Chronic Kidney Disease: Long-Term Cohort Study.
abstract: In nondialysis chronic kidney disease, ambulatory blood pressure (ABP) performs better than clinic BP in predicting outcome, but whether repeated assessment of ABP further refines prognosis remains ill-defined. We recruited 182 consecutive hypertensive patients with nondialysis chronic kidney disease who underwent 2 ABPs 12 months apart to evaluate the enhancement in risk stratification provided by a second ABP obtained 1 year after baseline on the risk (hazard ratio and 95% confidence interval) of composite renal end point (death, chronic dialysis, and estimated glomerular filtration rate decline ≥40%). The difference in daytime and nighttime systolic BP between the 2 ABPs (daytime and nighttime bias) was added to a survival model including baseline ABP. Net reclassification improvement was also calculated. Age was 65.6±13.4 years; 36% had diabetes mellitus and 36% had previous cardiovascular event; estimated glomerular filtration rate was 42.2±19.6 mL/min per 1.73 m(2), and clinic BP was 145±18/80±11 mm Hg. Baseline ABP (daytime, 131±16/75±10 and nighttime, 122±18/66±10 mm Hg) and daytime/nighttime BP goals (58.2% and 43.4%) did not change at month 12. Besides baseline ABP values, bias for daytime and nighttime systolic BP linearly associated with renal outcome (1.12, 1.04-1.21 and 1.18, 1.08-1.29 for every 5-mm Hg increase, respectively). Classification of patients at risk improved when considering nighttime systolic level at second ABP (net reclassification improvement, 0.224; 95% confidence interval, 0.005-0.435). Patients with first and second ABPs above target showed greater renal risk (2.15, 1.29-3.59 and 1.71, 1.07-2.72, for daytime and nighttime, respectively). In nondialysis chronic kidney disease, reassessment of ABP at 1 year further refines renal prognosis; such reassessment should specifically be considered in patients with uncontrolled BP at baseline.
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.). roberto.minutolo@unina2.it.
authors.forename: Roberto
authors.initials: R
authors.lastname: Minutolo
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.).
authors.forename: Francis B
authors.initials: FB
authors.lastname: Gabbai
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.).
authors.forename: Paolo
authors.initials: P
authors.lastname: Chiodini
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.).
authors.forename: Carlo
authors.initials: C
authors.lastname: Garofalo
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.).
authors.forename: Giovanna
authors.initials: G
authors.lastname: Stanzione
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.).
authors.forename: Maria Elena
authors.initials: ME
authors.lastname: Liberti
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.).
authors.forename: Mario
authors.initials: M
authors.lastname: Pacilio
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.).
authors.forename: Silvio
authors.initials: S
authors.lastname: Borrelli
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.).
authors.forename: Michele
authors.initials: M
authors.lastname: Provenzano
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.).
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Conte
authors.affiliation: From the Division of Nephrology, Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences (R.M., C.G., G.S., M.E.L., M. Pacilio, S.B., M. Provenzano, G.C., L.D.N.), Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine (P.C.), Second University of Naples, Naples, Italy; and Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School (F.B.G.).
authors.forename: Luca
authors.initials: L
authors.lastname: De Nicola
mesh_terms: D000368:Aged; D001794:Blood Pressure / Q000502:physiology*; D018660:Blood Pressure Monitoring, Ambulatory; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000503:physiopathology*; D007668:Kidney / Q000503:physiopathology*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000503:physiopathology*; D018570:Risk Assessment
keywords: blood pressure monitoring, ambulatory; diabetes mellitus; kidney failure, chronic; polycystic kidney, autosomal dominant; renal insufficiency, chronic