BACKGROUND Intraindividual blood pressure (BP) fluctuates dynamically over time. Previous studies suggested an adverse link between greater visit-to-visit variability (VVV) in systolic blood pressure (SBP) and various outcomes. However, these studies have significant limitations, such as a small size, inclusion of selected populations, and restricted outcomes. OBJECTIVES We investigated the association of increased VVV and all-cause mortality, cardiovascular events, and end-stage renal disease (ESRD) in a large cohort of U.S. veterans. METHODS From among 3,285,684 U.S. veterans with and without hypertension and normal estimated glomerular filtration rates (eGFR) during 2005 and 2006, we identified 2,865,157 patients who had 8 or more outpatient BP measurements. SBP variability (SBPV) was measured using the SD of all SBP values (normally distributed) in 1 individual. Associations of SD quartiles (<10.3, 10.3 to 12.7, 12.7 to 15.6, and ≥15.6 mm Hg) with all-cause mortality, incident coronary heart disease (CHD), stroke, and ESRD was examined using Cox models adjusted for sociodemographic characteristics, baseline eGFR, comorbidities, body mass index, SBP, diastolic BP, and antihypertensive medication use. RESULTS Several sociodemographic variables (older age, male sex, African-American race, divorced or widowed status) and clinical characteristics (lower baseline eGFR, higher SBP and DBP), and comorbidities (presence of diabetes, hypertension, cardiovascular disease, and lung disease) were all associated with higher intraindividual SBPV. The multivariable adjusted hazard ratios and 95% confidence intervals for SD quartiles 2 through 4 (compared to the first quartile) associated with all-cause mortality, CHD, stroke, and ESRD were incrementally higher. CONCLUSIONS Higher SBPV in individuals with and without hypertension was associated with increased risks of all-cause mortality, CHD, stroke, and ESRD. Further studies are needed to determine interventions that can lower SBPV and their impact on adverse health outcomes.

Background Obesity may be associated with worse clinical outcomes, including chronic kidney disease. It is unclear if this association is modified by age. Methods In a national cohort of over 3·3 million (n=3,376,187) US veterans with estimated glomerular filtration rate (eGFR) >60ml/min/1·73m2, we examined the association of body mass index (BMI) in patients of different age (<40, 40–<50, 50–<60, 60–<70, 70–<80, and ≥80 years old) with loss of kidney function and with all-cause mortality in logistic regression models and proportional hazards models adjusted for race, gender, comorbidities, medications, and baseline eGFR. Findings A U-shaped association between BMI and loss of kidney function was somewhat consistent and more prominent with advancing age, except in the patients ≤40 years old, in whom BMI did not appear to predict renal function impairment. The lowest risk for loss of kidney function was observed in patients with BMI 25– <30 kg/m2. BMI also displayed a U-shaped association with mortality, which was similar in all age groups. Interpretation BMI ≥30 kg/m2 is associated with rapid loss of kidney function in patients with eGFR ≥60 ml/min/1·73m2, and BMI ≥35 kg/m2 is also associated with high mortality. The former association is accentuated in older patients. A BMI of 25– <30 kg/m2 is associated with optimal clinical outcomes.