Masked Hypertension in Chronic Kidney Disease

慢性肾脏病中的隐匿性高血压

• 批准号: 8794422
• 负责人: RAJIV AGARWAL
• 金额: --
• 依托单位: RLR VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-04-01 至 2017-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8794422
• 关键词: Adult; Affect; Air; Albuminuria; Antihypertensive Agents; Bicycling; Blood Pressure; Blood Pressure Monitors; Body Composition; Body fat; Cardiovascular system; Categories; Cessation of life; Characteristics; Chronic Kidney Failure; Clinic; Cohort Studies; Cross-Sectional Studies; Data; Detection; Diagnosis; Diet; Echocardiography; End stage renal failure; Essential Hypertension; Evaluation; Event; Exercise; Funding; General Population; Goals; Gold; Health; Heart failure; High Prevalence; Home environment; Hour; Hypertension; Incidence; Intake; Kidney; Kidney Transplantation; Left Ventricular Mass; Location; Longitudinal Studies; Malignant - descriptor; Measurement; Measures; Meta-Analysis; Methods; Morbidity - disease rate; Natriuresis; Obesity; Organ; Outcome; Participant; Patients; Physical activity; Physiologic pulse; Plethysmography; Polysomnography; Population; Prevalence; Reporting; Risk Factors; Sleep; Sleep disturbances; Sodium; Stroke; Testing; Therapeutic; Time; Urine; Veterans; Wrist; adverse outcome; arterial stiffness; awake; blood pressure regulation; clinically significant; cohort; experience; hypertension treatment; improved; indexing; insight; masked hypertension; mortality; normotensive; outcome forecast; pressure; prognostic; prognostic value; white coat hypertension

DESCRIPTION (provided by applicant): Background: It is being increasingly recognized that compared to BP recordings in the clinic, BP recordings outside the clinic are stronger predictors of poor cardiorenal outcomes. When BP is recorded both in the clinic and outside, hypertension can be categorized depending on the location of BP recording. These categories include white coat hypertension, sustained normotension (NTN), sustained hypertension (HTN), and masked hypertension (MHTN). MHTN is defined as normal BP in the clinic but elevated BP outside the clinic. Our meta-analysis revealed that 40% of CKD patients thought to be normotensive in fact had MHTN. The largest CKD cohort studied to date included a cross-sectional analysis of 209 patients (enabled through this period of VAMR funding) who were selected because they had normal BP (<140/90 mmHg) in the clinic. We found that the prevalence of MHTN was ~40%. For the first time we demonstrated that the diagnosis of MHTN was reproducible. This has not been reported in the past even among patients without CKD. Moreover, MHTN in our cohort was associated with greater left ventricular mass index, increased arterial stiffness, greater albuminuria, and nocturnal natriuresis. Long-term goal: The overall goal of this study in Veterans with CKD is to investigate target organ damage, prognosis, and mechanisms of "masked hypertension ", defined by an average awake ambulatory pressure of 125/75 mm Hg or more and clinic BP below 130/80 mm Hg. Hypothesis: We hypothesize that NTN, MHTN and HTN is a continuum. We hypothesize that a graded relationship among NTN, MHTN and HTN will exist such that with a worse hypertension category will: 1) have greater worsening of hypertension and therefore greater end-organ damage; 2) will experience greater all-cause mortality and cardiovascular and renal morbidity; 3) have associations with greater target organ damage and mortality the magnitude of which will depend on how MHTN is defined; and 4) experience greater sleep disturbances, reduced day-time physical activity, increased body fat, and greater exercise-induced increased BP. Also, dietary Na intake will modulate subsequent increase in ambulatory BP and other adverse outcomes. Goals: This proposed study will enable us to determine (1) the incidence of worsening of hypertension and the occurrence of target organ damage among NTN, MHTN, and HTN, (2) Compare the incidence of cardiorenal events (hospitalized heart failure, MI, stroke, ESRD, kidney transplantation, death) among the hypertension categories (3) Compare the prognostic value of two definitions of MHTN (a CKD-specific definition, noted above and the conventional definition of MHTN) and (4) examine the mechanistic relationship of MHTN with sleep disturbances, reduced day-time activity, increasing adiposity and increments in ambulatory BP with greater sodium intake. Methods: This project will study 450 subjects with CKD with NTN, MHTN, and HTN. Participants will have their clinic BP measured on three occasions, ambulatory BP once, and home BP twice over a one month period. Target organ damage will be assessed using LV mass and pulse wave velocity by echocardiogram and 24 hour urine for albuminuria. Examinations will be repeated biannually. Sleep will be measured using portable multichannel overnight sleep monitoring. Body composition will be measured by the gold-standard measurement of air-displacement plethysmography (Bod Pod). Activity will be measured by 7-day wrist accelerometer. Greater pressor effect with physical activity will be measured on a bicycle ergometer. We will follow for ESRD and cardiovascular events. Novelty: This proposal will provide new insights on the prognostic implications and mechanisms of masked hypertension in patients with CKD. Relevance to VA: To the extent that this study increases our understanding of the differences between clinic and out of clinic BP monitoring, it will help to explain why the latter is a better indicator of prognosis. The evaluation of target organ damage, ESRD, and cardiovascular events among those with masked hypertension may unmask its malignant characteristics and improve our ability to treat this condition more effectively.

描述（由申请人提供）： 背景资料：越来越多的人认识到，与诊所内的BP记录相比，诊所外的BP记录是不良心肾结局的更强预测因子。当血压记录在诊所和外面，高血压可以根据血压记录的位置进行分类。这些类别包括白色被毛高血压、持续性正常血压（NTN）、持续性高血压（HTN）和隐匿性高血压（MHTN）。MHTN的定义是在诊所内血压正常，但在诊所外血压升高。我们的荟萃分析显示，40%被认为血压正常的CKD患者实际上患有MHTN。迄今为止研究的最大CKD队列包括对209名患者（通过VAMR资助期间启用）的横断面分析，这些患者因在诊所血压正常（<140/90 mmHg）而被选择。我们发现MHTN的患病率约为40%。我们首次证明了MHTN的诊断是可重复的。这在过去甚至在没有CKD的患者中也没有报道。 此外，在我们的队列中，MHTN与更大的左心室质量指数，动脉僵硬度增加，更多的蛋白尿和夜间尿钠排泄有关。长期目标：本研究在CKD退伍军人中的总体目标是研究靶器官损伤、预后和“隐匿性高血压“的机制，”隐匿性高血压“定义为平均清醒动态血压≥ 125/75 mm Hg，门诊血压低于130/80 mm Hg。假设：我们假设NTN，MHTN和HTN是一个连续体。我们假设NTN、MHTN和HTN之间存在分级关系，高血压类别越严重，高血压的恶化程度越大，终末器官损害越大; 2）全因死亡率和心血管及肾脏发病率越高; 3）靶器官损害和死亡率越高，其程度取决于MHTN的定义;和4）经历更大的睡眠障碍、减少的白天身体活动、增加的体脂肪和更大的运动诱发的血压升高。此外，膳食钠摄入量将调节随后的动态血压升高和其他不良结局。目标：这项拟议的研究将使我们能够确定（1）NTN、MHTN和HTN之间高血压恶化和靶器官损害的发生率，（2）比较心肾事件的发生率（3）比较两种MHTN定义的预后价值（CKD特异性定义，如上所述和MHTN的常规定义）和（4）检查MHTN与睡眠障碍、白天活动减少、肥胖增加和随着钠摄入量增加动态血压增加的机制关系。方法：本项目将研究450例伴有NTN、MHTN和HTN的CKD患者。参与者将在一个月内测量三次诊所BP，一次动态BP，两次家庭BP。将通过超声心动图和24小时尿白蛋白，使用LV质量和脉搏波速度评估靶器官损伤。考试将每半年重复一次。将使用便携式多通道夜间睡眠监测仪测量睡眠。将通过空气置换体积描记法（Bod Pod）的金标准测量来测量身体组成。活动将通过7天手腕加速计测量。将在自行车测力计上测量体力活动的更大升压效应。我们将随访ESRD和心血管事件。新奇：该提案将为CKD患者中隐性高血压的预后意义和机制提供新的见解。与VA的相关性：在某种程度上，这项研究增加了我们对诊所和诊所外血压监测之间差异的理解，这将有助于解释为什么后者是一个更好的预后指标。对隐匿性高血压患者靶器官损害、终末期肾病和心血管事件的评估可能会揭示其恶性特征，并提高我们更有效治疗这种疾病的能力。