Apparent Treatment-Resistant Hypertension Assessed by Office and Ambulatory Blood Pressure in Chronic Kidney Disease—A Report from the Chronic Renal Insufficiency Cohort Study

BackgroundApparent treatment-resistant hypertension is common in patients with CKD. Whether measurement of 24-hour ambulatory BP monitoring is valuable for risk-stratifying patients with resistant hypertension and CKD is unclear.MethodsWe analyzed data from the Chronic Renal Insufficiency Cohort study, a prospective study of participants (n=1186) with CKD. Office BP was measured using standardized protocols; ambulatory BP was measured using Spacelabs monitors. Apparent treatment-resistant hypertension was defined on the basis of office BP, ambulatory BP monitoring, and use of more than three antihypertensive medications. Outcomes were composite cardiovascular disease, kidney outcomes, and mortality. Groups were compared using Cox regression analyses with a control group of participants without apparent treatment-resistant hypertension.ResultsOf 475 participants with apparent treatment-resistant hypertension on the basis of office BP, 91.6% had apparent treatment-resistant hypertension confirmed by ambulatory BP monitoring. Unadjusted event rates of composite cardiovascular disease, kidney outcomes, and mortality were higher in participants with ambulatory BP monitoring–defined apparent treatment-resistant hypertension compared with participants without apparent treatment-resistant hypertension. In adjusted analyses, the risks of composite cardiovascular disease (hazard ratio, 1.27; 95% confidence interval [95% CI], 0.59 to 2.7), kidney outcomes (hazard ratio, 1.68; 95% CI, 0.88 to 3.21), and mortality (hazard ratio, 1.27; 95% CI, 0.5 to 3.25) were not statistically significantly higher in participants with ambulatory BP monitoring–defined apparent treatment-resistant hypertension compared with participants without apparent treatment-resistant hypertension.ConclusionsIn our study population with CKD, most patients with apparent treatment-resistant hypertension defined on the basis of office BP have apparent treatment-resistant hypertension confirmed by ambulatory BP monitoring. Although ABPM-defined apparent treatment-resistant hypertension was not independently associated with clinical outcomes, it identified participants at high risk for adverse clinical outcomes.

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Adverse Health Outcomes Associated With Refractory and Treatment-Resistant Hypertension in the Chronic Renal Insufficiency Cohort

Hypertension ◽

10.1161/hypertensionaha.120.15064 ◽

2021 ◽

Vol 77 (1) ◽

pp. 72-81 ◽

Cited By ~ 1

Author(s):

Michael G. Buhnerkempe ◽

Vivek Prakash ◽

Albert Botchway ◽

Bemi Adekola ◽

Jordana B. Cohen ◽

...

Keyword(s):

Renal Insufficiency ◽

Health Outcomes ◽

Resistant Hypertension ◽

Chronic Renal Insufficiency ◽

Hazard Ratio ◽

Renal Outcome ◽

Treatment Resistant ◽

Increased Risk ◽

Significant Difference ◽

Time Varying Covariates

Refractory hypertension (RfH) is a severe phenotype of antihypertension treatment failure. Treatment-resistant hypertension (TRH), a less severe form of difficult-to-treat hypertension, has been associated with significantly worse health outcomes. However, no studies currently show how health outcomes may worsen upon progression to RfH. RfH and TRH were studied in 3147 hypertensive participants in the CRIC (Chronic Renal Insufficiency Cohort study). The hypertensive phenotype (ie, no TRH or RfH, TRH, or RfH) was identified at the baseline visit, and health outcomes were monitored at subsequent visits. Outcome risk was compared using Cox proportional hazards models with time-varying covariates. A total of 136 (4.3%) individuals were identified with RfH at baseline. After adjusting for participant characteristics, individuals with RfH had increased risk for the composite renal outcome across all study years (50% decline in estimated glomerular filtration rate or end-stage renal disease; hazard ratio for study years 0–10=1.73 [95% CI, 1.42–2.11]) and the composite cardiovascular disease outcome during later study years (stroke, myocardial infarction, or congestive heart failure; hazard ratio for study years 0–3=1.25 [0.91–1.73], for study years 3–6=1.50 [0.97–2.32]), and for study years 6–10=2.72 [1.47–5.01]) when compared with individuals with TRH. There was no significant difference in all-cause mortality between those with refractory versus TRH. We provide the first evidence that RfH is associated with worse long-term health outcomes compared with TRH.

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Progression of retinopathy and incidence of cardiovascular disease: findings from the Chronic Renal Insufficiency Cohort Study

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2019-315333 ◽

2020 ◽

pp. bjophthalmol-2019-315333

Author(s):

Juan E Grunwald ◽

Maxwell Pistilli ◽

Gui-Shuang Ying ◽

Maureen G Maguire ◽

Ebenezer Daniel ◽

...

Keyword(s):

Risk Factors ◽

Cardiovascular Disease ◽

Cohort Study ◽

Renal Insufficiency ◽

Chronic Renal Insufficiency ◽

Kidney Diseases ◽

Vascular Pathology ◽

Cvd Risk Factors ◽

Cvd Risk ◽

Increased Risk

PurposeChronic kidney disease (CKD) patients often develop cardiovascular disease (CVD) and retinopathy. The purpose of this study was to assess the association between progression of retinopathy and concurrent incidence of CVD events in participants with CKD.DesignWe assessed 1051 out of 1936 participants in the Chronic Renal Insufficiency Cohort Study that were invited to have fundus photographs obtained at two timepoints separated by 3.5 years, on average.MethodsUsing standard protocols, presence and severity of retinopathy (diabetic, hypertensive or other) and vessel diameter calibre were assessed at a retinal image reading centre by trained graders masked to study participants’ information. Participants with a self-reported history of CVD were excluded. Incident CVD events were physician adjudicated using medical records and standardised criteria. Kidney function and proteinuria measurements along with CVD risk factors were obtained at study visits.ResultsWorsening of retinopathy by two or more steps in the EDTRS retinopathy grading scale was observed in 9.8% of participants, and was associated with increased risk of incidence of any CVD in analysis adjusting for other CVD and CKD risk factors (OR 2.56, 95% CI 1.25 to 5.22, p<0.01). After imputation of missing data, these values were OR=1.66 (0.87 to 3.16), p=0.12.ConclusionProgression of retinopathy is associated with higher incidence of CVD events, and retinal-vascular pathology may be indicative of macrovascular disease even after adjustment for kidney diseases and CVD risk factors. Assessment of retinal morphology may provide important information when assessing CVD in patients with CKD.

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Retinopathy and the Risk of Cardiovascular Disease in Patients With Chronic Kidney Disease (from the Chronic Renal Insufficiency Cohort Study)

The American Journal of Cardiology ◽

10.1016/j.amjcard.2015.08.015 ◽

2015 ◽

Vol 116 (10) ◽

pp. 1527-1533 ◽

Cited By ~ 10

Author(s):

Juan E. Grunwald ◽

Maxwell Pistilli ◽

Gui-Shuang Ying ◽

Maureen Maguire ◽

Ebenezer Daniel ◽

...

Keyword(s):

Cardiovascular Disease ◽

Chronic Kidney Disease ◽

Cohort Study ◽

Kidney Disease ◽

Renal Insufficiency ◽

Chronic Renal Insufficiency

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Use of the CHA2DS2-VASc Score for Risk Stratification of Hospital Admissions Among Patients With Cardiovascular Diseases Receiving a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study (Preprint)

10.2196/preprints.12790 ◽

2018 ◽

Author(s):

Jen-Kuang Lee ◽

Chi-Sheng Hung ◽

Ching-Chang Huang ◽

Ying-Hsien Chen ◽

Pao-Yu Chuang ◽

...

Keyword(s):

Cardiovascular Disease ◽

Cohort Study ◽

Cardiovascular Diseases ◽

Clinical Outcomes ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Lipid Lowering ◽

Fourth Generation ◽

Control Group ◽

Significant Prognostic Factor

BACKGROUND Telehealth programs are generally diverse in approaching patients, from traditional telephone calling and texting message and to the latest fourth-generation synchronous program. The predefined outcomes are also different, including hypertension control, lipid lowering, cardiovascular outcomes, and mortality. In previous studies, the telehealth program showed both positive and negative results, providing mixed and confusing clinical outcomes. A comprehensive and integrated approach is needed to determine which patients benefit from the program in order to improve clinical outcomes. OBJECTIVE The CHA2DS2-VASc (congestive heart failure, hypertension, age >75 years [doubled], type 2 diabetes mellitus, previous stroke, transient ischemic attack or thromboembolism [doubled], vascular disease, age of 65-75 years, and sex) score has been widely used for the prediction of stroke in patients with atrial fibrillation. This study investigated the CHA2DS2-VASc score to stratify patients with cardiovascular diseases receiving a fourth-generation synchronous telehealth program. METHODS This was a retrospective cohort study. We recruited patients with cardiovascular disease who received the fourth-generation synchronous telehealth program at the National Taiwan University Hospital between October 2012 and June 2015. We enrolled 431 patients who had joined a telehealth program and compared them to 1549 control patients. Risk of cardiovascular hospitalization was estimated with Kaplan-Meier curves. The CHA2DS2-VASc score was used as the composite parameter to stratify the severity of patients’ conditions. The association between baseline characteristics and clinical outcomes was assessed via the Cox proportional hazard model. RESULTS The mean follow-up duration was 886.1 (SD 531.0) days in patients receiving the fourth-generation synchronous telehealth program and 707.1 (SD 431.4) days in the control group (P<.001). The telehealth group had more comorbidities at baseline than the control group. Higher CHA2DS2-VASc scores (≥4) were associated with a lower estimated rate of remaining free from cardiovascular hospitalization (46.5% vs 54.8%, log-rank P=.003). Patients with CHA2DS2-VASc scores ≥4 receiving the telehealth program were less likely to be admitted for cardiovascular disease than patients not receiving the program. (61.5% vs 41.8%, log-rank P=.01). The telehealth program remained a significant prognostic factor after multivariable Cox analysis in patients with CHA2DS2-VASc scores ≥4 (hazard ratio=0.36 [CI 0.22-0.62], P<.001) CONCLUSIONS A higher CHA2DS2-VASc score was associated with a higher risk of cardiovascular admissions. Patients accepting the fourth-generation telehealth program with CHA2DS2-VASc scores ≥4 benefit most by remaining free from cardiovascular hospitalization.

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