The impact of hypertension on chronic kidney disease and end-stage renal disease is greater in men than women: a systematic review and meta-analysis

Abstract

Background: Hypertension (HTN) is an established risk factor for chronic kidney disease (CKD) and end-stage renal disease (ESRD). Whether sex differences in the effect of HTN on CKD and ESRD incidence exist remains unclear. This systematic review and meta-analysis was conducted to evaluate the relative impact of HTN on CKD and ESRD risk in women compared with men.

Methods: We systematically searched Embase and PubMed for cohort studies until 24 July 2020. Studies were selected if they reported a sex-specific association between systolic blood pressure (SBP) and CKD or ESRD. Random effects meta-analyses with inverse variance weighting were used to pool sex-specific relative risks (RRs) and the women-to-men ratio of RRs (the RRR) for incident CKD and ESRD.

Results: Data from six cohorts, including 2,382,712 individuals and 6856 incident CKD events, and 833 ESRD events, were included in the meta-analysis. The RR for incident CKD or ESRD associated with HTN (SBP ≥140 mmHg) versus ideal BP (SBP < 120 mmHg) was 1.56 (95% CI, 1.39-1.75) in women and 2.06 (95% CI, 1.64-2.60) in men. The RR for incident CKD or ESRD was 23% lower in women than in men RRR 0.77 [95% CI, 0.63-0.95] with no significant heterogeneity between studies (p-value for Q test = 0.507, I² = 17.7%).

Conclusion: HTN confers about a fifth lower excess risk of incident CKD or ESRD in women than men. Sex differences in onset, duration, and severity of some risk factors, such as albuminuria, diabetes, cardiovascular disease, obesity, and socioeconomic status, may explain part of the excess risk in men. Another explanation could be that women might be under-diagnosed and less likely to initiate dialysis. Future studies are needed to demonstrate the mechanisms responsible for the observed sex difference.

Fig. 1

Flow chart of the study selection

Fig. 2

Summary of the maximum-adjusted relative risks and 95% confidence intervals, by study, showing all the blood pressure comparisons analyzed. We categorized the reported systolic blood pressure thresholds from each study as Ideal, SBP < 120 mmHg; Normal, SBP 120–129 mmHg; High-normal, SBP 130–139 mmHg; Prehypertension, SBP 120–139 mmHg; Hypertension, SBP ≥140 mmHg; Stage 1 Hypertension, SBP 140–159 mmHg; Stage 2 Hypertension, SBP 160–179 mmHg; Stage 3/4 Hypertension, SBP ≥180 mmHg

Fig. 3

The maximum-adjusted pooled relative risk and 95% confidence intervals for chronic kidney disease and end-stage renal disease in women (left panel) and men (right panel), comparing individuals with Hypertension versus ideal blood pressure

Fig. 4

The maximum-adjusted women-to-men relative risk ratio and 95% confidence intervals for chronic kidney disease and end-stage renal disease, comparing individuals in Hypertension versus ideal blood pressure