Resistant Hypertension, Time-Updated Blood Pressure Values and Renal Outcome in Type 2 Diabetes Mellitus

Abstract

Background: Apparent treatment resistant hypertension (aTRH) is highly prevalent in patients with type 2 diabetes mellitus (T2D) and entails worse cardiovascular prognosis. The impact of aTRH and long-term achievement of recommended blood pressure (BP) values on renal outcome remains largely unknown. We assessed the role of aTRH and BP on the development of chronic kidney disease in patients with T2D and hypertension in real-life clinical practice.

Methods and results: Clinical records from a total of 29 923 patients with T2D and hypertension, with normal baseline estimated glomerular filtration rate and regular visits during a 4-year follow-up, were retrieved and analyzed. The association between time-updated BP control (ie, 75% of visits with BP <140/90 mm Hg) and the occurrence of estimated glomerular filtration rate <60 and/or a reduction ≥30% from baseline was assessed. At baseline, 17% of patients had aTRH. Over the 4-year follow-up, 19% developed low estimated glomerular filtration rate and 12% an estimated glomerular filtration rate reduction ≥30% from baseline. Patients with aTRH showed an increased risk of developing both renal outcomes (adjusted odds ratio, 1.31 and 1.43; P<0.001 respectively), as compared with those with non-aTRH. No association was found between BP control and renal outcomes in non-aTRH, whereas in aTRH, BP control was associated with a 30% (P=0.036) greater risk of developing the renal end points.

Conclusions: ATRH entails a worse renal prognosis in T2D with hypertension. BP control is not associated with a more-favorable renal outcome in aTRH. The relationship between time-updated BP and renal function seems to be J-shaped, with optimal systolic BP values between 120 and 140 mm Hg.

Keywords: albuminuria; blood pressure; chronic kidney disease; diabetes (kidney); glomerular filtration rate; resistant hypertension.

Figure 1

Flow diagram for selection of study patients. eGFR indicates estimated glomerular filtration rate.

Figure 2

Cumulative incidence of renal outcomes in patients with and without aTRH and T2D. ATRH indicates apparent treatment resistant hypertension; CI, confidence interval; eGFR, estimated glomerular filtration rate; T2D, type 2 diabetes mellitus. *P<0.001 vs No‐aTRH. Adjusted odds ratios for eGFR <60 mL/min per 1.73 m², 1.31 (CI 1.19–1.44; P<0.001), for eGFR reduction >30% from baseline, 1.43 (CI 1.28–1.58; P<0.001), for eGFR <60 or reduction >30% from baseline, 1.30 (CI 1.19–1.42; P<0.001).

Figure 3

Blood pressure changes during follow‐up. ATRH indicates apparent treatment resistant hypertension; BP, blood pressure; blood pressure control (BPC) refers to the proportion of visits with systolic and diastolic blood pressure <140/90 mm Hg.

Figure 4

Mean yearly eGFR slope on the basis of the presence of aTRH and BPC. ATRH indicates apparent treatment resistant hypertension; eGFR, estimated glomerular filtration rate; BP, blood pressure control (BPC) refers to the proportion of visits with systolic and diastolic blood pressure <140/90 mm Hg. *P<0.01 vs No‐aTRH with BPC; ^# P<0.01 vs No‐aTRH with NoBPC.

Figure 5

A, Cumulative incidence of renal end point (eGFR <60) on the basis of albuminuria status and aTRH. ALB indicates albuminuria; ATRH, apparent treatment resistant hypertension; CI, confidence interval; eGFR, estimated glomerular filtration rate. *Adjusted odds ratios for Alb+/aTRH− vs Alb−/aTRH− 2.00 (CI 1.80–2.23), P<0.001 and ^#for Alb+/aTRH+ vs Alb−/aTRH+ 1.67 (CI 1.38–2.02), P<0.001. B, Cumulative incidence of renal end point (eGFR <60) on the basis of albuminuria status and time‐updated BPC. ALB indicates albuminuria; BPC, blood pressure control; eGFR, estimated glomerular filtration rate. *Adjusted odds ratios for Alb+/BPC− vs Alb−/BPC− 1.98 (CI 1.79–2.19), P<0.001 and ^#for Alb+/BPC+ vs Alb−/BPC+ 1.71 (CI 1.34–2.18), P<0.001.

Figure 6

Odds ratios of reaching renal end point (eGFR <60 mL/min per 1.73 m²) on the basis of time‐updated mean SBP in patients with and without aTRH, taking 140 mm Hg in non aTRH as reference category. Patients were grouped into 10 mm Hg subsets (ie, those between 136 and 144 in the group labeled 140 and so on). The subset of patients with No‐aTRH and 140 mm Hg SBP was taken as the reference group. ATRH indicates apparent treatment resistant hypertension; eGFR, estimated glomerular filtration rate; SBP, systolic blood pressure. Odds ratio for single renal outcome with 95% confidence interval.