Diurnal patterns of BP in African Americans with hypertensive kidney disease: results from the AASK cohort study (original) (raw)
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Collegium Antropologicum, 2009
Doppler can evaluate renal vascular resistance, and resistance index (RI) highly correlates with blood pressure and renal function in various pathological conditions. Purpose of the study was to measure and compare renal Doppler indices in patients with newly-diagnosed essential hypertension (EH) and in healthy subjects; to determine changes of Doppler indices in patients after six-months monotherapy with either the AT II blocker (valsartane) or calcium channel blocker (niphedipine); to determine which drug has better renoprotective effect. 65 healthy controls were examined, as well as 69 patients with the newly-diagnosed EH, without signs of the target organ damage. Duplex Doppler US of interlobar intrarenal arteries was performed, and RI, acceleration index (AI) and acceleration time (AT) measured. Antihypertensive monotherapy was performed with vaslartane in 34 patients and with niphedipine in 35 patients. Doppler was repeated after the six-months therapy. RI in patients with the 1. stage of EH is significantly higher compared to the controls (p<0.001), and significantly lower compared to the stage 2. of EH (p<0.001). The significant decrease of systolic (p<0.001) and dyastolic blood pressure (BP) (p<0.001) was noted after the therapy. RI in healthy examinees (RI=0.59±0.023) is significantly lower than in EH (RI=0.66±0.26) (p<0.001), while AI is significantly higher (p<0.001), and AT is significantly lower (p<0.001). In patients treated with valsartane and those treated with niphedipine, the RIs are significantly lower than before (p<0.001), while AIs were significantly higher, and ATs were significantly lower after the therapy after the therapy with both drugs. RIs in patients treated with valsartane (RI = 0.615 ± 0.036) are significantly lower than RIs of patients treated with niphedipine (RI=0.642±0.030) (p<0.01) after therapy. Regression analysis for the predictive values of RI, AT, AI in relation to the age-standardized values of systolic and diastolic BP of healthy examinees and patients with hypertension has demonstrated that RI is the strongest and statistically significant predictor in all groups of examinees. Six-months monotherapy of EH with valsartane or with niphedipine is equally efficient in the decrease of the blood pressure, but valsartane has more favourable effect on kidney. Resistance index measured in intrarenal arteries is the best parameter of Doppler spectrum in the evaluation of the effects of antihypertensive therapy on the kidney.
Hypertension in Chronic Kidney Disease Part 2
B lood pressure (BP) is characterized by high variability, including changes beat-to-beat (very short term), within 24 hours (short term), from day to day (midterm), and between visits spaced by weeks, months, seasons, and even years (long term). These variations can be estimated by means of continuous beat-to-beat BP recordings, repeated conventional office BP measures, 24-hour ambulatory BP monitoring (ABPM), or home BP monitoring (HBPM) over longer time windows (Table). A main advantage of ABPM over other BP measurement techniques is represented by its ability to track BP changes occurring in daily life conditions and during 24 hours, thus allowing assessment of overall BP variability (BPV) as well as identification of its specific components, such as nocturnal hypertension and altered day-tonight BP profiles (ie, morning BP rise, nondipping pattern of BP) which become manifest early in the course of chronic kidney disease (CKD). These alterations are even more significant in subjects with end-stage renal disease (ESRD) mainly, but not exclusively, because of the marked reduction in intravascular volume immediately after hemodialysis followed by the progressive increase in volemia throughout the interdialytic period, 2 combined with an enhanced sympathetic activity. The higher frequency of alterations in 24-hour BP profiles and BPV in subjects with CKD and in those with ESRD not only makes a proper assessment and achievement of BP control more difficult in these subjects but may be prognostically relevant on the background of the evidence from longitudinal and observational studies indicating that increased BPV may predict the development of cardio-vascular and renal disease, over and above the contribution of elevated mean BP levels per se 3–11 (Figure 1). The purpose of this review is to address the currently available evidence on the role of ABPM and HBPM for the assessment and management of alterations in circadian BP profiles and in BPV in patients with CKD.
Pulse pressure and inhibition of renin-angiotensin system in chronic kidney disease
Nephrology Dialysis Transplantation, 2005
Background. Elevated pulse pressure (PP) is an indicator of poor outcome in hypertensives in the general population and on haemodialysis. The prognostic value of PP in pre-dialysis patients with chronic kidney disease (CKD) stages 4/5 and its interaction with renin-angiotensin system (RAS) inhibitors is unknown.
Controlled Clinical Trials, 1996
In September, 2000, the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health called an early halt to the amlodipine arm of the African American Study of Kidney Disease and Hypertension (AASK) trial after careful deliberation by an independent data and safety monitoring board. An interim analysis of the AASK at 3 years revealed a renoprotective effect of the angiotensin-converting enzyme inhibitor ramipril as compared to the dihydropyridine calcium channel blocker (DHP-CCB) amlodipine in patients with mild to moderate renal insufficiency. This differential effect was independent of the blood pressure (BP) levels reached and was evident in proteinuric patients and suggestive in patients with baseline proteinuria < 300 mg/d, but was not conclusive. The AASK trial data suggest that DHP-CCBs should be used cautiously in the presence of mild to moderate renal insufficiency. Judgment should be reserved for the use of other CCBs, such as verapamil or diltiazem, since these are fundamentally different CCBs with the potential for a different impact on hypertensive nephrosclerosis. The blinded observation period for AASK will be completed at the end of September, 2001, at which time additional, clinically useful information is expected to become available. (c)2001 Le Jacq Communications, Inc.
Aim: Contrasts in the prescient estimation of daytime systolic circulatory strain (SBP) and evening SBP by wandering blood pressure observing on renal results have not been completely explored in persistent kidney sickness patients. This investigation analyzed the prognostic incentive among daytime and evening SBP on renal results in CKD. Methods and Results: 428 patients were interested in this upcoming retrospective study. End-phase renal illness (ESRD) or mortality was the composite renal endpoint. Our current research was conducted at Lahore General Hospital, Lahore from March 2019 to February 2020. Cox models have been used to assess the daytime and night time association SBP with renal outcomes. 150 kidney functions were present (ESRD, 136; destruction, 23). Multivariable Cox tests found that the peril proportions (PDPs) [95 percent stretch (CI)] were 1.16 (1.03-1.27) (P=0.03) and 1.16 (1.056-1.28) (P<0.02) for each 10-mmHg rise during the day and evening. The SBP quartile was also compared to SBP (95 percent) and SBP quartile (0.70-0.25), 1.09 (0.61-1.94) and 1.58 (0.88-2.85; P=0,13; trend=0.17; SSB (0.62-1.97), 1:32 (0.75-2.29) and 1.83 (1.01-3.32; trend=0.047) (P) and SBP (0.047), each individual quartile in contrast, for the first day and/or evening time. (P=0.047) Conclusion: Night-time SBP seemed better than daytime SBP for anticipating renal results in this populace of patients.
Renal Artery Stenosis in Patients With Resistant Hypertension
The American Journal of Cardiology, 2013
The aim of the study was to assess the significance of renal translesional pressure gradients in predicting improvement in resistant hypertension after stenting for moderate renal artery stenosis (RAS). In 37 patients with RAS and resistant hypertension subjected to renal stenting, translesional pressure gradients both at rest and hyperemic were measured using a pressure guidewire. Twenty-four-hour ambulatory blood pressure measurements were performed in all patients on admission and 3 months after the intervention. Angioplasty was successful in all patients, with reduction of artery diameter stenosis from 60 -12% to 10 -6% (p <0.0001). At 3 months, with maintained hypotensive agents (4.0 -1.4 vs 4.0 -1.6), significant reductions in systolic blood pressure (SBP) and diastolic blood pressure were noted (L5 and L2 mm Hg, respectively). In multivariate analysis, the mean baseline gradient (MBG) was the only independent predictor of improvement in SBP (regression coefficient 0.292; standard error 0.11; p value 0.014). In the receiver operating characteristic curve analysis, MBG had a larger area under the curve than other parameters, and the MBG >22 mm Hg had the highest sensitivity, specificity, and accuracy (50%, 95%, and 0.74%, respectively) in predicting hypertension improvement after stenting. In patients with MBG >22 mm Hg, SBP decreased by 12 versus 3 mm Hg (p <0.01) in patients with MBG £22 mm Hg, whereas diastolic blood pressure in both groups decreased by 3 versus 1 mm Hg, respectively (NS). In conclusion, MBG value of >22 mm Hg provides the highest accuracy in predicting hypertension improvement after stenting for moderate RAS in patients with resistant hypertension. Ó 2013 Elsevier Inc. All rights reserved. (Am J Cardiol 2013;112:1417e1420)
Pretreatment blood pressure reliably predicts progression of chronic nephropathies
Kidney …, 2000
Pretreatment blood pressure reliably predicts progression of times after treatment administration are questionable. chronic nephropathies. Background. Random, nontimed blood pressure (BP) measurements in the outpatient clinic may fail to provide reliable information on actual daily BP control in renal patients on Progressive renal function deterioration occurs in most chronic antihypertensive therapy. forms of chronic nephropathy [1]. A recognized major Methods. In a cohort of 163 patients with proteinuric chronic nephropathies followed prospectively with repeated BP and determinant of renal injury in these circumstances is glomerular filtration rate (GFR) measurements, we compared arterial hypertension: the higher the levels of arterial baseline and follow-up pretreatment, morning ("trough," meablood pressure (BP), the greater the risk of a given pasured by standard procedures, and "0 minutes," measured by tient to develop renal failure in the long term [2, 3]. an automatic device) and post-treatment (120 minutes) mea-On the other hand, many clinical studies are available surements, with BP monitored up to 600 minutes after treatment administration. We then evaluated which BP value most indicating that BP reduction is protective [reviewed in reliably predicted GFR decline (⌬GFR) and progression to 4]. In most intervention trials aimed at evaluating the end-stage renal failure (ESRF) over a median (interquartile effect of different antihypertensive regimens on disease range) follow-up of 20 (9 to 25) months. progression to renal failure, reported values of arterial Results. GFR decline was more reliably predicted by systolic BP were random measurements in outpatient clinics, as compared with diastolic BP and by pretreatment as compared to post-treatment BP, regardless of the timing and which may lead to different results depending on the method of measurement, respectively. In particular, at the 120time BP is measured [5-8]. Actually, in some studies, minute baseline and follow-up measurements, systolic BP had BP was measured in the morning just before the adminisno predictive value in patients with less severe renal insuffitration of antihypertensive medication, when the residciency and baseline diastolic BP, regardless of the level of renal dysfunction. The BP predictive value was remarkably higher ual effect of treatment is minimal ("trough" BP) [9-11]. in ramipril than in conventionally treated patients. All follow-In a few others, the BP was measured shortly after the up-but no baseline-measurements reliably predicted the risk administration of the antihypertensive treatment, conof ESRF in the entire study group. ceivably when the medication has achieved the peak Conclusions. In patients with progressive chronic nephropaeffect [12]. However, most of the studies did not report thies, systolic BP and pretreatment morning BP measurements are the most reliable predictors of disease outcome and may the timing of BP measurements [5-8], which renders data serve to guide antihypertensive therapy in routine clinical activinterpretation even more difficult. One also has to take ities and in prospective controlled trials, particularly in patients into account that random measurements in the outpaon angiotensin-converting enzyme inhibitor therapy. Reliabiltient clinic do not distinguish sustained hypertension from "white-coat hypertension" and, even more impor-1 Gruppo Italiano di Studi Epidemiologici in Nefrologia tant, fail to provide information on daily response to medication [13].
Journal of the American Society of Hypertension, 2014
H ypertension is considered one of the most important risk factors for stroke, coronary heart disease (CHD), heart failure (HF), and end-stage renal disease (ESRD). 1,2 In a subset of patients with hypertension, blood pressure (BP) remains inadequately controlled despite the use of multiple classes of antihypertensive medication. The concept of resistant hypertension is familiar to many clinicians with one widely accepted definition provided in a scientific statement published by the American Heart Association in 2008. 3 In this statement, treatment-resistant hypertension (TRH) was defined as uncontrolled BP despite the use of ≥3 antihypertensive medication classes or controlled BP while treated with ≥4 antihypertensive medication classes. Ideally, one of these classes should be a diuretic. The concept of TRH was derived "to identify patients who are at high risk of having reversible causes of hypertension and patients who, because of persistently high BP levels, may benefit from special diagnostic and therapeutic considerations". 3 Using data from the 2005 to 2008 US National Health and Nutrition Examination Survey, Egan et al 4 estimated the prevalence of apparent TRH (aTRH) to be 11.8% among individuals Abstract-Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled hypertension despite the use of ≥3 antihypertensive medication classes or controlled hypertension while treated with ≥4 antihypertensive medication classes. Although a high prevalence of aTRH has been reported, few data are available on its association with cardiovascular and renal outcomes. We analyzed data on 14 684 Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants to determine the association between aTRH (n=1870) with coronary heart disease, stroke, allcause mortality, heart failure, peripheral artery disease, and end-stage renal disease. We defined aTRH as blood pressure not at goal (systolic/diastolic blood pressure ≥140/90 mm Hg) while taking ≥3 classes of antihypertensive medication or taking ≥4 classes of antihypertensive medication with blood pressure at goal during the year 2 ALLHAT study visit (1996-2000). Use of a diuretic was not required to meet the definition of aTRH. Follow-up occurred through 2002. The multivariable adjusted hazard ratios (95% confidence intervals) comparing participants with versus without aTRH were as follows: coronary heart disease (1.44 [1.18-1.76]), stroke (1.57 [1.18-2.08]), all-cause mortality (1.30 [1.11-1.52]), heart failure (1.88 [1.52-2.34]), peripheral artery disease (1.23 [0.85-1.79]), and end-stage renal disease (1.95 [1.11-3.41]). aTRH was also associated with the pooled outcomes of combined coronary heart disease (hazard ratio, 1.47; 95% confidence interval, 1.26-1.71) and combined cardiovascular disease (hazard ratio, 1.46; 95% confidence interval, 1.29-1.64). These results demonstrate that aTRH increases the risk for cardiovascular disease and end-stage renal disease. Studies are needed to identify approaches to prevent aTRH and reduce risk for adverse outcomes among individuals with aTRH. (Hypertension. 2014;64:1012-1021.) • Online Data Supplement