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NDT Advance Access originally published online on January 18, 2006
Nephrology Dialysis Transplantation 2006 21(5):1257-1262; doi:10.1093/ndt/gfk057
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Published by Oxford University Press on behalf of ERA-EDTA. [2006]

Original Articles: Clinical Nephrology

Association of low blood pressure with increased mortality in patients with moderate to severe chronic kidney disease

Csaba P. Kovesdy1,2, Bhairvi K. Trivedi1, Kamyar Kalantar-Zadeh3,4 and John E. Anderson5

1 Salem Veterans Affairs Medical Center, Salem, VA, 2 University of Virginia, Charlottesville, VA, 3 Los Angeles Biomedical Research Institute at Harbor – UCLA Medical Center, Torrance, CA, 4 David Geffen School of Medicine at UCLA, Los Angeles, CA and 5 Johns Hopkins Bayview Medical Center, Baltimore, MD, USA

Correspondence and offprint requests to: Csaba P. Kovesdy, MD, FASN, CCI, Division of Nephrology, Salem VA Medical Center, 1970 Roanoke Blvd, Salem, VA 24153, USA. Email: csaba.kovesdy{at}med.va.gov

Background. Blood pressure shows an inverse association with mortality in patients with chronic kidney disease (CKD) on dialysis. It is unclear if the same phenomenon exists in patients with CKD not yet on dialysis.

Methods. We examined the association of systolic (SBP) and diastolic (DBP) blood pressure with all-cause mortality in a historical prospective cohort of 860 patients (age 68.1±10.1 years, 99.1% male, 24.4% black) with estimated glomerular filtration rate (GFR) <60 ml/min/1.73 m2. We used Cox models to adjust for the effects of age, race, diabetes mellitus, atherosclerotic cardiovascular disease (ASCVD), congestive heart failure, smoking, antihypertensive medications, body mass index, GFR, albumin, cholesterol, haemoglobin and proteinuria. To examine the role of comorbidities, we performed subgroup analyses based on prevalent ASCVD status and level of estimated GFR.

Results. Higher SBP and higher DBP were both associated with lower mortality [adjusted hazard ratio (95% confidence interval) for SBP 133–154, 155–170 and >170 mmHg, compared with <133 mmHg, respectively: 0.61 (0.44–0.85), 0.62 (0.45–0.87) and 0.68 (0.49–0.96); and for DBP 65–75, 76–86 and >86 mmHg, compared with <65 mmHg: 0.85 (0.62–1.18), 0.72 (0.52–1.00) and 0.60 (0.41–0.86)]. The same association was present for both SBP and DBP only in subgroups with GFR ≤30 ml/min/1.73 m2 and for DBP only in the subgroup with ASCVD.

Conclusions. Lower blood pressure is associated with higher mortality in patients with moderate to severe CKD, but interactions with kidney function and with ASCVD suggest that blood pressure may play a surrogate rather than a causative role in this association.

Keywords: cardiovascular disease; chronic kidney disease; diastolic blood pressure; glomerular filtration rate; mortality; systolic blood pressure


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