Showing papers by "Jackson T. Wright published in 2015"

A Randomized Trial of Intensive versus Standard Blood-Pressure Control

Abstract: BACKGROUND The most appropriate targets for systolic blood pressure to reduce cardiovascular morbidity and mortality among persons without diabetes remain uncertain. METHODS We randomly assigned 9361 persons with a systolic blood pressure of 130 mm Hg or higher and an increased cardiovascular risk, but without diabetes, to a systolic blood-pressure target of less than 120 mm Hg (intensive treatment) or a target of less than 140 mm Hg (standard treatment). The primary composite outcome was myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. RESULTS At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensive-treatment group and 136.2 mm Hg in the standard-treatment group. The intervention was stopped early after a median follow-up of 3.26 years owing to a significantly lower rate of the primary composite outcome in the intensive-treatment group than in the standard-treatment group (1.65% per year vs. 2.19% per year; hazard ratio with intensive treatment, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P<0.001). All-cause mortality was also significantly lower in the intensive-treatment group (hazard ratio, 0.73; 95% CI, 0.60 to 0.90; P=0.003). Rates of serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure, but not of injurious falls, were higher in the intensive-treatment group than in the standard-treatment group. CONCLUSIONS Among patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive-treatment group. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01206062.).

Time-Updated Systolic Blood Pressure and the Progression of Chronic Kidney Disease: A Cohort Study

Abstract: Background Blood pressure (BP) is often inadequately controlled in patients with chronic kidney disease (CKD). Previous reports of the longitudinal association between achieved level of BP and end-stage renal disease (ESRD) have not incorporated time-updated BP with appropriate adjustment for known confounders.

Blood Pressure and Risk of All-Cause Mortality in Advanced Chronic Kidney Disease and Hemodialysis The Chronic Renal Insufficiency Cohort Study

Abstract: Studies of hemodialysis patients have shown a U-shaped association between systolic blood pressure (SBP) and mortality. These studies have largely relied on dialysis-unit SBP measures and have not evaluated whether this U-shape also exists in advanced chronic kidney disease, before starting hemodialysis. We determined the association between SBP and mortality at advanced chronic kidney disease and again after initiation of hemodialysis. This was a prospective study of Chronic Renal Insufficiency Cohort participants with advanced chronic kidney disease followed through initiation of hemodialysis. We studied the association between SBP and mortality when participants (1) had an estimated glomerular filtration rate <30 mL/min/1.73 m2 (n=1705), (2) initiated hemodialysis and had dialysis-unit SBP measures (n=403), and (3) initiated hemodialysis and had out-of-dialysis-unit SBP measured at a Chronic Renal Insufficiency Cohort study visit (n=326). Cox models were adjusted for demographics, cardiovascular risk factors, and dialysis parameters. A quadratic term for SBP was included to test for a U-shaped association. At advanced chronic kidney disease, there was no association between SBP and mortality (hazard ratio, 1.02 [95% confidence interval, 0.98-1.07] per every 10 mm Hg increase). Among participants who started hemodialysis, a U-shaped association between dialysis-unit SBP and mortality was observed. In contrast, there was a linear association between out-of-dialysis-unit SBP and mortality (hazard ratio, 1.26 [95% confidence interval, 1.14-1.40] per every 10 mm Hg increase). In conclusion, more efforts should be made to obtain out-of-dialysis-unit SBP, which may merit more consideration as a target for clinical management and in interventional trials.

The effects of weight change on glomerular filtration rate

Abstract: BACKGROUND Little is known about the effect of weight loss/gain on kidney function. Analyses are complicated by uncertainty about optimal body surface indexing strategies for measured glomerular filtration rate (mGFR). METHODS Using data from the African-American Study of Kidney Disease and Hypertension (AASK), we determined the association of change in weight with three different estimates of change in kidney function: (i) unindexed mGFR estimated by renal clearance of iodine-125-iothalamate, (ii) mGFR indexed to concurrently measured BSA and (iii) GFR estimated from serum creatinine (eGFR). All models were adjusted for baseline weight, time, randomization group and time-varying diuretic use. We also examined whether these relationships were consistent across a number of subgroups, including tertiles of baseline 24-h urine sodium excretion. RESULTS In 1094 participants followed over an average of 3.6 years, a 5-kg weight gain was associated with a 1.10 mL/min/1.73 m(2) (95% CI: 0.87 to 1.33; P < 0.001) increase in unindexed mGFR. There was no association between weight change and mGFR indexed for concurrent BSA (per 5 kg weight gain, 0.21; 95% CI: -0.02 to 0.44; P = 0.1) or between weight change and eGFR (-0.09; 95% CI: -0.32 to 0.14; P = 0.4). The effect of weight change on unindexed mGFR was less pronounced in individuals with higher baseline sodium excretion (P = 0.08 for interaction). CONCLUSION The association between weight change and kidney function varies depending on the method of assessment. Future clinical trials should examine the effect of intentional weight change on measured GFR or filtration markers robust to changes in muscle mass.

Recognition and Management of Hypertension in Older Persons: Focus on African Americans

Abstract: Hypertension is the most commonly diagnosed condition in persons aged 60 and older and is the single most important risk factor for cardiovascular disease (ischemic heart disease, heart failure, and stroke), kidney disease, and dementia. More than half of individuals with hypertension in the United States are aged 60 and older. Hypertension disproportionately affects African Americans, with all age groups, including elderly adults, having a higher burden of hypertension-related complications than other U.S. populations. Multiple clinical trials have demonstrated the beneficial effects of blood pressure (BP) reduction on cardiovascular morbidity and mortality, with most of the evidence in individuals aged 60 and older. Several guidelines have recently been published on the specific management of hypertension in individuals aged 60 and older, including in high-risk groups such as African Americans. Most recommend careful evaluation, thiazide diuretics and calcium-channel blockers for initial drug therapy in most African Americans, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in those with chronic kidney disease or heart failure. Among the areas of controversy is the recommended target BP in African Americans aged 60 and older. A recent U.S. guideline recommended raising the systolic BP target from less than 140 mmHg to less than 150 mmHg in this population. This article will review the evidence and current guideline recommendations for hypertension treatment in older African Americans, including the rationale for continuing to recommend a SBP target of less than 140 mmHg in this population.

The Benefits of Detecting and Treating Mild Hypertension: What We Know, and What We Need to Learn

Abstract: In this issue, Sundstrom and colleagues assess evidence on the effects of blood pressure reduction on cardiovascular outcomes in patients with stage 1 hypertension and Piper and associates evaluate...

Abstract 17124: Sex Differences in the Incidence of Peripheral Artery Disease (PAD) in the Chronic Renal Insufficiency Cohort (CRIC)

Abstract: Introduction: Chronic kidney disease (CKD) results in an increased risk of peripheral artery disease (PAD). However, the epidemiology of PAD in CKD, and particularly how the incidence differs according to sex remains incompletely defined. We sought to define how the epidemiology of peripheral arterial disease (PAD) in chronic kidney disease (CKD) differs according to sex and age. Methods: The Chronic Renal Insufficiency Cohort (CRIC) is a multi-center, prospective cohort study of CKD participants. Fine and Gray methods were used to determine the cumulative incidence of PAD, defined by an ankle brachial index (ABI) Results: The mean age of the 3,174 participants in this study was 56.6 years and consisted of 55% males. Over a median follow-up of 5.9 years, 17.8% developed PAD and 11.1% died. Females had a 1.72-fold greater adjusted PAD risk compared to men (95% CI 1.44-2.06, p Conclusions: Females with CKD have a higher PAD risk compared to males at younger ages. There is an important need to improve our understanding of the biological and clinical basis for these differences.

Research Article Baseline characteristics of African Americans in the Systolic Blood Pressure Intervention Trial

Abstract: The Systolic Blood Pressure Intervention Trial (SPRINT) will compare treatment to a systolic blood pressure goal of <120 mm Hg to treatment to the currently recommended goal of <140 mm Hg for effects on incident cardiovascular, renal, and neurologic outcomes including cognitive decline The objectives of this analysis are to compare baseline characteristics of African American (AA) and non-AA SPRINT participants and explore factors associated with uncontrolled blood pressure (BP) by race SPRINT enrolled 9361 hypertensive participants aged older than 50 years This cross-sectional analysis examines sociodemographics, baseline characteristics, and study measures among AAs compared with non-AAs AAs made up 31% of participants AAs (compared with non-AAs) were younger and less frequently male, had less education, and were more likely uninsured or covered by Medicaid In addition, AAs scored lower on the cognitive screening test when compared with non-AAs Multivariate logistic regression analysis found BP control rates to <140/90 mm Hg were higher for AAs who