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(Hypertension. 2007;50:474.)
© 2007 American Heart Association, Inc.

Original Articles

Association of Antihypertensive Therapy and Diastolic Hypotension in Chronic Kidney Disease

Carmen A. Peralta; Michael G. Shlipak; Christina Wassel-Fyr; Hayden Bosworth; Brian Hoffman; Susana Martins; Eugene Oddone; Mary K. Goldstein

From the General Internal Medicine Section (C.A.P., M.G.S.), San Francisco Veterans Affairs Medical Center, San Francisco, Calif; Department of Medicine (C.A.P., M.G.S., C.W-F.), Division of Nephrology (C.A.P.), University of California, San Francisco; Center for Health Services Research in Primary Care (H.B., E.O.), Durham Veteran’s Affairs Medical Center, Durham, NC; Center for Health Services Research in Primary Care, Department of Medicine, Division of General Internal Medicine, Department of Psychiatry and Behavioral Sciences and Center for Aging and Human Development, and School of Nursing (H.B.), Duke University, Durham, NC; Veteran’s Affairs Hospital Boston-West Roxbury and Harvard Medical School (B.H.), Boston, Mass; Geriatrics Research Education and Clinical Center (S.M., M.K.G.), Veteran’s Affairs Palo Alto Health Care System, Palo Alto, Calif; Division of General Internal Medicine (E.O.), Duke University Medical Center Health Care System, Durham, NC; and the Center for Primary Care and Outcomes Research (M.K.G.), Stanford University School of Medicine, Palo Alto, Calif.

Correspondence to Michael G. Shlipak, General Internal Medicine, University of California San Francisco, Veteran’s Affairs Medical Center, General Internal Medicine Section 111A1, 4150 Clement St, San Francisco, CA 94121. E-mail shlip{at}itsa.ucsf.edu

The extent to which chronic kidney disease (CKD) affects achievement of blood pressure targets is not comprehensively understood. We evaluated the effects of CKD (estimated glomerular filtration rate: <60 mL/min per 1.73 m²) on achievement of blood pressure control (nondiabetic: <140/90 mm Hg; diabetic: <130/85 mm Hg) using data from the Guidelines for Drug Therapy of Hypertension Trial. This 15-month study obtained outpatient blood pressures from 3 Veteran’s Affairs institutions. Among 9985 subjects with hypertension, we evaluated the association of CKD with achieved control and antihypertensive medication use. We also explored the association between the number of antihypertensives and systolic, diastolic, and pulse pressure. After 15 months, 41% of participants met blood pressure targets. CKD was not associated with control (adjusted odds ratio: 1.04; 95% CI: 0.93 to 1.15). However, CKD was associated with higher odds of use of 3 medications among nondiabetic subjects (odds ratio: 1.46; 95% CI: 1.25 to 1.71) and diabetic subjects (odds ratio: 1.40; 95% CI: 1.17 to 1.66). A significant interaction was observed between CKD and the number of antihypertensives as determinants of diastolic and pulse pressures. Among non-CKD participants, a greater number of antihypertensives (0 compared with 4) was associated with wider pulse pressure (5.2 mm Hg; P<0.001), mainly because of higher systolic pressures (3.6 mm Hg; P=0.001). Among participants with CKD, although greater numbers of antihypertensives were associated with even wider pulse pressures (8.3 mm Hg; P<0.001), this was primarily because of lower diastolic pressures (4.8 mm Hg; P<0.01). Among participants with CKD, greater use of antihypertensives was associated with lower diastolic pressures. Given recent evidence suggesting adverse effects of diastolic hypotension, these results suggest potential risks in patients with CKD from aggressive attempts to control systolic blood pressure.

Key Words: chronic kidney disease • hypertension • diastolic blood pressure • pulse pressure • antihypertensive drugs

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