Epidemiology Of Hypertension In Chronic Kidney Disease

Background:Our study aimed to detect the epidemiology,compliance and treatment of hypertension in CKD by a multi-center cross-sectional investment,and to demonstrate the clinical and ABPM features of hypertensive CKD patients with left ventricular abnormality by a single center studyMethods:We conducted a multicenter,cross-sectional study in 22 hospitals throughout China from Feb-2013 to Jan-2014 to invest the prevalence,awareness and treatment of hypertension by blood pressure measurement and questionnaire.According to the altitude of study centers,patients were stratified into 3 different geographic areas:South,including Guangdong,Fujian,Zhejiang and Jiangxi Province;North,including Beijing,Henan,Xinjiang,Inner Mongolia and Heilongjiang Province;Central,including Shanghai,Sichuan,Jiangsu and Hubei Province.Clinical and ABPM data of hypertensive non-dialytic CKD patients from Oct-2012 to Sep-2013 from a single center were collected to demonstrate ABPM and left ventricular abnormality patterns.Single variant analysis and multivariate Logistic regression were used to determine the associated factorsResults:The cross-sectional study recruited 6079 CKD patients from CKD1-5 stages.Primary glomerulonephritis was the most frequent cause(61%),followed by hypertensive and ischemic nephropathy(14.4%)and diabetic kidney disease(14.4%).Patients in CKD1-5 stages counted for24.1%、19.6%、19.8%、9.4%and 27.1%.4328 had hypertension,4129 were diagnosed previously,and 4054 were reveiving medication.Prevalence,awareness,treatment rate were 71.2%、95.4%、98.2%.The North(77.6%)and Central area(75.4%)had higher prevalence than the South(60.4%).Calcium Channel Blocker(CCB)was the most frequent antihypertensive agent used by CKD patients(72.9%),followed by Angiotensin-Ⅱ Receptor Blocker(ARB)(53.9%),β-Blockers(24.4%)and Angiotensin Converting Enzyme Inhibitor(ACEI)(16.4%).The most popular combination was CCB+ARB(17.2%)andβ-blockers+CCB(7.2%).Compared to CKD 1 stage,patients in CKD 1,2,3a,3b,4,5 stage had increased risk of hypertension of 1.3、2.4、2.68、5.26、13.35 folds,respectively.DKD patients had higher prevalence of hypertension than PGN Odds Ratio(OR)=1.8,95%CI=1.1-2.94.Patients with aging(>65 vs.<45 OR=3.7,95%CI:2.9-4.71)、hypertension family history(OR=2.63,95%CI:2.16-3.22)、diabetes(OR=2.14,95%CI:1.57-2.93)、obesity(BMI>28kg/m^2:OR=1.91,95%CI:1.43-2.57)、dyslipidemia(OR=1.52,95%CI:1.26-1.82)、hyperuricemia(OR=1.35,95%CI 1.11-1.64)or proteinuria(Urine albumin/creatinine>300mg/g:OR=1.3,95%CI:1.03-1.65)had higer prevalence of hypertension.Elderly(>65 vs.<45 OR=2.3,95%CI:1.48-3.56)、patients with hypertension family history(OR=2.2,95%CI:1.47-3.28)had higher awareness rate。Elderly had higher treatment rate(OR=2.41,95%CI:1.42-4.1).73.9%hypertensive CKD patients measured BP had home,and 49.4%had good compliance.Patients between 45-65yrs(vs.<45,OR=0.77,95%CI:0.62-0.95),with DKD(vs.PGN,OR=0.6,95%CI:0.47-0.75)or reporting side effects(OR=0.73,95%CI:0.53-0.99)had worse compliance.Patients with better education and hypertension family history had better compliance.41.1%hypertensive CKD who were taking antihypertensive medication controlled their BP<140/90mmHg.The North had the lowest control rate(31.7%),and South(39.3%),Central(46.1%).For hypertensive CKD patients<60yrs and with proteinuria,control rate was 16.7%(<130/80mmHg).The North had the lowest control rate(8.8%),South and Central had no significant difference(21.1%vs.16.7%,P>0.05).For controlling to<140/90mmHg,ARB had higher control rate than CCB and ACEI in single therapy(64.6%,vs.ACEI48.4%,CCB 37.5%,P<0.01).In 2 drug combination,ARB+ACEI controlled better than ARB+CCB(62.5%vs.42.9%,P<0.0001).In 3 drug combination,ARB+ACEI+CCB controlled better than ARB+CCB+β-blockers(44.7%vs.26.9%,P<0.0001)Patients with GFR declining(CKD4 vs.CKD1:OR=0.62,95%CI:0.46-0.82;CKD5 vs.CKD1,OR=0.54,95%CI:0.42-0.69)、DKD[vs.PGN:OR=0.56,95%CI:0.45-0.71)、smoking(OR=0.81,95%CI:0.68-0.96)had lower control rate Patients using ARB(OR=1.64,95%CI:1.38-1.94)、ACEI(OR=1.51,95%CI:1.22-1.87)or HBPM(OR=1.3,95%CI:1.08-1.56)controlled BP better。or hypertensive CKD patients<60yrs and with proteinuria,,Female(OR=1.78,95%CI:1.31-2.41)、patients with HBPM use(OR=1.53,95%CI:1.03-2.27)controlled BP betterIn 327 hypertensive non-dialytic CKD patients,29.3%had left ventricular hypertrophy(LVH),for which 11%were Concentric Hypertrophy(CH)and 18.3%were Eccentric Hypertrophy(EH).Patients with LVH had lower eGFR and higher preoteinuria level.Patients with Concentric Hypertrophy had lower EF 62%vs.66%,P<0.01).Paitents with LVH had higher day and night blood pressure level,load,pulse pressure and non-dipper rate(CH 96.4%,EH 87.2%vs.Normal 67.6%,P<0.01),and patients with CH had higher 24h and night diastolic BP Coefficient of Variation(CV)and AASI(0.47 vs.0.4,P<0.05)Multivariate regression analysis showed that LVH was associated with elevated night SBP(OR=1.038,95%CI 1.023-1.053),male gender(OR=0.335,95%CI:0.186-0.606)and declining GFR(OR=0.984,95%CI 0.975-0.993).9.5%patients had Concentric Remodeling(CR),with significantly increased day and night BP level,load and variability,but without any change in eGFR,proteinuria,pulse pressure,AASI and noon-dipper rate.Multivariate regression analysis showed that CR was associated with night DBP elevation(OR=1.053,95%CI 1.019-1.088)and increased night SBP standard deviation(OR=1.139,95%CI:1.025-1.265).Blood Pressure Morning Surge happened in 32.8%-38%hypertensive non-dialytic CKD patients,it had no significant difference between patients with or without left ventricular abnormalityConclusion:The multicenter cross-sectional study showed that prevalence of hypertension in CKD was high but with poor control.ACEI/ARB use and HBPM could help with hypertension control.Night blood pressure elevation was a risk factor of LVH.Patients with elevated night DBP and increased night SBP standard deviation were more likely to develop concentric remodeling,who should be provided with early intervention.