title: Different components of blood pressure are associated with increased risk of atherosclerotic cardiovascular disease versus heart failure in advanced chronic kidney disease.
abstract: Blood pressure is a modifiable risk for cardiovascular disease (CVD). Among hemodialysis patients, there is a U-shaped association between blood pressure and risk of death. However, few studies have examined the association between blood pressure and CVD in patients with stage 4 and 5 chronic kidney disease. Here we studied 1795 Chronic Renal Insufficiency Cohort (CRIC) Study participants with estimated glomerular filtration rate <30 ml/min per 1.73 m2and not on dialysis. The association of systolic (SBP), diastolic (DBP), and pulse pressure with the risk of physician-adjudicated atherosclerotic CVD (stroke, myocardial infarction, or peripheral arterial disease) and heart failure was tested using Cox regression adjusted for demographics, comorbidity and medications. There was a significant association with higher SBP (adjusted hazard ratio 2.04 [95% confidence interval: 1.46-2.84]) for SBP over 140 vs under 120 mmHg, higher DBP (2.52 [1.54-4.11]) for DBP >90 mm Hg versus <80 mm Hg and higher pulse pressure (2.67 [1.82-3.92]) for pulse pressure >68 mm Hg versus <51 mm Hg with atherosclerotic CVD. For heart failure, there was a significant association with higher pulse pressure only (1.42 [1.05-1.92]) for pulse pressure >68 mm Hg versus <51 mmHg, but not for SBP or DBP. Thus, among participants with stage 4 and 5 chronic kidney disease, there was an independent association between higher SBP, DBP, and pulse pressure with the risk of atherosclerotic CVD, whereas only higher pulse pressure was independently associated with a greater risk of heart failure. Further trials are needed to determine whether aggressive reduction of blood pressure decreases the risk of CVD events in patients with stage 4 and 5 chronic kidney disease.
authors.affiliation: Department of Medicine, University of Washington, Seattle, Washington, USA. Electronic address: nbansal@nephrology.washington.edu.
authors.forename: Nisha
authors.initials: N
authors.lastname: Bansal
authors.affiliation: Department of Biostatistics and Epidemiology, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Charles E
authors.initials: CE
authors.lastname: McCulloch
authors.affiliation: Department of Biostatistics and Epidemiology, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Feng
authors.initials: F
authors.lastname: Lin
authors.affiliation: Department of Medicine, University of Washington, Seattle, Washington, USA.
authors.forename: Cassianne
authors.initials: C
authors.lastname: Robinson-Cohen
authors.affiliation: Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
authors.forename: Mahboob
authors.initials: M
authors.lastname: Rahman
authors.affiliation: National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA.
authors.forename: John W
authors.initials: JW
authors.lastname: Kusek
authors.affiliation: Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Amanda H
authors.initials: AH
authors.lastname: Anderson
authors.affiliation: Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Dawei
authors.initials: D
authors.lastname: Xie
authors.affiliation: Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Raymond R
authors.initials: RR
authors.lastname: Townsend
authors.affiliation: Department of Medicine, University of Chicago, Chicago, Illinois, USA.
authors.forename: Claudia M
authors.initials: CM
authors.lastname: Lora
authors.affiliation: Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
authors.forename: Jackson
authors.initials: J
authors.lastname: Wright
authors.affiliation: Division of Research, Kaiser Permanente Division of Research, Oakland, California, USA.
authors.forename: Alan S
authors.initials: AS
authors.lastname: Go
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA.
authors.forename: Akinlolu
authors.initials: A
authors.lastname: Ojo
authors.affiliation: Department of Medicine, Tulane University, New Orleans, Louisiana, USA.
authors.forename: Arnold
authors.initials: A
authors.lastname: Alper
authors.affiliation: School of Public Health, Tulane University, New Orleans, Louisiana, USA.
authors.forename: Eva
authors.initials: E
authors.lastname: Lustigova
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Magda
authors.initials: M
authors.lastname: Cuevas
authors.affiliation: Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Radhakrishna
authors.initials: R
authors.lastname: Kallem
authors.affiliation: Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, Kaiser Permanente Division of Research, Oakland, California, USA.
authors.forename: Chi-Yuan
authors.initials: CY
authors.lastname: Hsu
mesh_terms: D000368:Aged; D050197:Atherosclerosis / Q000209:etiology*; D001794:Blood Pressure; D003971:Diastole; D005260:Female; D006333:Heart Failure / Q000209:etiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000503:physiopathology; D013599:Systole
keywords: blood pressure; cardiovascular disease; chronic kidney disease