Blood Pressure and Pulse Pressure Effects on Renal Outcomes in the Veterans Affairs Diabetes Trial (VADT)

Abstract

OBJECTIVEBlood pressure (BP) control for renal protection is essential for patients with type 2 diabetes. Our objective in this analysis of Veterans Affairs Diabetes Trial (VADT) data was to learn whether on-study systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) affected renal outcomes measured as albumin-to-creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR).RESEARCH DESIGN AND METHODSThe VADT was a prospective, randomized study of 1,791 veterans with type 2 diabetes to determine whether intensive glucose control prevented major cardiovascular events. In this post hoc study, time-varying covariate survival analyses and hazard ratios (HR) were used to determine worsening of renal outcomes.RESULTSCompared with SBP 105–129 mmHg, the risk of ACR worsening increased significantly for SBP 130–139 mmHg (HR 1.88 [95% CI 1.28–2.77]; P = 0.001) and for SBP ≥140 mmHg (2.51 [1.66–3.78]; P < 0.0001). Compared with a PP range of 40–49 mmHg, PP <40 was associated with significantly lowered risk of worsening ACR (0.36 [0.15–0.87]; P = 0.022) and PP ≥60 with significantly increased risk (2.38 [1.58–3.59]; P < 0.0001). Analyses of BP ranges associated with eGFR worsening showed significantly increased risk with rising baseline SBP and an interaction effect between SBP ≥140 mmHg and on-study A1C. These patients were 15% more likely than those with SBP <140 mmHg to experience eGFR worsening (1.15 [1.00–1.32]; P = 0.045) for each 1% (10.9 mmol/mol) A1C increase.CONCLUSIONSSBP ≥130 mmHg and PP >60 mmHg were associated with worsening ACR. The results suggest that treatment of SBP to <130 mmHg may lessen ACR worsening. The interaction between SBP ≥140 mmHg and A1C suggests that the effect of glycemic control on reducing progression of renal disease may be greater in hypertensive patients.

Hypertension, blood pressure control and diabetic retinopathy in a large population-based study

“…In addition, except for one population-based study, none has looked into the association of pulse pressure (PP, calculated as the difference between systolic and diastolic BP) with DR [12]. PP >60 mm Hg has been shown to be associated with increased risk of cardiovascular disease (CVD) and adverse renal outcomes in patients with type 2 diabetes [13,14].…”

Aortic stiffness and ambulatory blood pressure as predictors of diabetic kidney disease: a competing risks analysis from the Rio de Janeiro Type 2 Diabetes Cohort Study

“…Control of blood glucose levels and BP is of utmost importance for the prevention of diabetic microvascular complications. In particular, BP and blood glucose control is important for preventing development and progression of abnormal albuminuria in DKD [5][6][7][8]. However, whether intensive control hinders progression to ESRD in individuals with type 2 diabetes remains debatable [5][6][7][8][9][10].…”

Which Measurement of Blood Pressure Is More Associated With Albuminuria in Patients With Type 2 Diabetes: Central Blood Pressure or Peripheral Blood Pressure?

“…Moreover, we demonstrated in this study that PP was also associated with albuminuria in patients with type 2 diabetes, although AUC for PP to identify albuminuria did not show significant difference from that of peripheral SBP. PP is known to be an independently stronger determinant of UAE than mean arterial pressure and this phenomenon is noted in patients with diabetes …”

“…PP is known to be an independently stronger determinant of UAE than mean arterial pressure 27 and this phenomenon is noted in patients with diabetes. [28][29][30]…”