Sex difference in ambulatory blood pressure control associates with risk of ESKD and death in CKD patients receiving stable nephrology care

Abstract

Background It is unknown whether faster progression of chronic kidney disease (CKD) in men than in women relates to differences in ambulatory blood pressure (ABP) levels. Methods We prospectively evaluated 906 hypertensive CKD patients (553 men) regularly followed in renal clinics to compare men vs women in terms of ABP control (daytime<135/85 and nighttime BP < 120/70 mmHg) and risk of all-cause mortality and end-stage kidney disease (ESKD) Results Age, eGFR and use of renin-angiotensin system inhibitors were similar in men and women while proteinuria was lower in women (0.30 g/24h IQR 0.10-1.00 vs 0.42 g/24h, IQR 0.10-1.28, P = 0.025). No sex-difference was detected in office BP levels; conversely, daytime and nighttime BP were higher in men (134±17/78±11 and 127±19/70±11 mmHg) than in women (131±16/75±11, P = 0.005/P<0.001 and 123±20/67±12, P = 0.006/P<0.001) with ABP goal achieved more frequently in women (39.1% vs 25.1%, P < 0.001). During a median follow-up of 10.7 years, 275 patients reached ESKD (60.7% men) and 245 died (62.4% men). Risks of ESKD and mortality (Hazard Ratio and 95% CI), adjusted for demographic and clinical variables, were higher in men (1.34, 1.02-1.76 and 1.36, 1.02-1.83, respectively). Adjustment for office BP at goal did not modify this association. In contrast, adjustment for ABP at goal attenuated the increased risk in men for ESKD (1.29, 0.98-1.70) and death (1.31, 0.98-1.77). In the fully adjusted model, ABP at goal was associated with reduced risk of ESKD (0.49, 0.34-0.70) and death (0.59, 0.43-0.80). No interaction between sex and ABP at goal on the risk of ESKD and death was found, suggesting that ABP-driven risks are consistent in males and females. Conclusions Our study highlights that higher ABP significantly contributes to higher risks of ESKD and mortality in men.

Sex differences in ambulatory blood pressure levels, control, and phenotypes of hypertension in kidney transplant recipients

“…In addition, the distribution of BP profiles was also quite different between sexes ( P < 0.001), with men having lower prevalence of controlled hypertension (10.9 vs. 17.6%) and white-coat effect (14.3 vs. 21.5%) but higher prevalence of masked hypertension (19.5 vs. 15.3%) and sustained hypertension (55.3 vs. 45.6%) than women. In adjusted analyses, this difference in ambulatory BP control was suggested to be the key contributor to the higher risk of men for incident ESKD and mortality [20]. Our findings are quite similar to the above results by Minutolo et al .…”

Sex differences in ambulatory blood pressure levels, control and phenotypes of hypertension in hemodialysis patients

“…In an observational study including 906 CKD patients without kidney replacement therapy, Minutolo et al [18] showed that men exhibit similar BP levels and control by office but higher BP levels and worse control by ABPM criteria compared to women. This worse ambulatory BP control in men was a significant contributor to the increased risk of incident ESKD and mortality [18]. In addition, a recent cross-sectional study including 136 male and 69 female stable KTRs showed that BP levels, hypertension prevalence and control are similar by office but significantly different by ABPM criteria between male and female KTRs [19].…”

“…In patients with CKD, the presence of between-sexes differences in ambulatory BP levels, hypertension prevalence and control has been recently reported. In an observational study including 906 CKD patients without kidney replacement therapy, Minutolo et al [18] showed that men exhibit similar BP levels and control by office but higher BP levels and worse control by ABPM criteria compared to women. This worse ambulatory BP control in men was a significant contributor to the increased risk of incident ESKD and mortality [18].…”

“…The underlying mechanisms for the aforementioned disparities between men and women are not fully understood. The presence of significantly higher ambulatory BP levels and worse BP control has been recently suggested to be a key factor contributing to the higher cardiovascular and renal risk observed in male CKD patients before dialysis [18]. Another recent study showed that ambulatory BP levels, and control are also significantly different between male and female kidney transplant recipients (KTRs) [19].…”

Hypertension as Cardiovascular Risk Factor in Chronic Kidney Disease

“…68 In CKD, an elevated nighttime systolic BP (>125 mm Hg) is associated with a two- to four-fold increase in the risk of fatal and nonfatal cardiovascular events and renal death, 69 the risk being higher in men than in women. 70 In another study, target organ damages such as proteinuria or left ventricular hypertrophy were more frequent in patients with CKD with an elevated nighttime BP than in those with a controlled BP in the clinic. 41 At last, in 217 patients with CKD, the nondipping pattern was associated with an increased cardiovascular risk, but not when adjusted for other risk factors.…”