TY - JOUR
T1 - Troponin i and NT-proBNP and the association of systolic blood pressure with outcomes in incident hemodialysis patients
T2 - The choices for healthy outcomes in caring for ESRD (CHOICE) study
AU - Shafi, Tariq
AU - Zager, Philip G.
AU - Sozio, Stephen M.
AU - Grams, Morgan E.
AU - Jaar, Bernard G.
AU - Christenson, Robert H.
AU - Boulware, L. Ebony
AU - Parekh, Rulan S.
AU - Powe, Neil R.
AU - Coresh, Josef
N1 - Funding Information:
Support: The CHOICE Study was supported by the Agency for Healthcare Quality and Research (grant R01-HS-008365 ) from July 1994 to June 1999, the National Heart, Lung and Blood Institute (grant RO1-HL-62985 ) from September 2000 to June 2006, and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK; grant R01-DK-059616 ) from September 2000 to June 2005 and (grant R01-DK-080123 ) from August 2008 to June 2013. Dr Shafi is supported by NIDDK grant K23-DK-083514 and the NKF of Maryland Professional Development Award. Dr Parekh was supported by NIDDK grant R01-DK-072367 . Dr Coresh is supported in part as an American Heart Association established investigator (01-4019-7N). Dr Powe is supported in part by NIDDK grants K24-DK-02643 and R01-DK-080123. Reagents for serum cTnI and NT-proBNP were provided by Siemens Health Care Diagnostics to the University of Maryland, where serum cTnI and NT-proBNP measurements were performed. Siemens had no role in the design, analysis, and interpretation of data or preparation of this manuscript. Research reported in this publication was supported by the NIDDK of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
PY - 2014/9
Y1 - 2014/9
N2 - Background There is uncertainty regarding treatment of hypertension in hemodialysis patients due to the observed J-shaped association between blood pressure (BP) and death. We hypothesized that this association reflects confounding by cardiovascular disease (CVD) and that stratification by CVD biomarkers, cardiac troponin I (cTnI) and N-terminal fragment of prohormone brain natriuretic peptide (NT-proBNP), might change this association. Study Design National prospective cohort study. Setting & Participants 446 incident hemodialysis patients. Predictor Predialysis systolic BP. Outcomes Mortality (all-cause and CVD) and first CVD event assessed using Cox regression adjusted for demographics, comorbid conditions, and clinical factors. Measurements Participants with cTnI level ≥ 0.1 ng/mL or NT-proBNP level ≥ 9,252 pg/mL were classified as the high-biomarker group; remaining participants were included in the low-biomarker group. Results Participants in the high-biomarker group (n = 138 [31%]) were older (61 vs 57 years) and had a higher prevalence of CVD (67% vs 23%), but similar baseline BPs (152 vs 153 mm Hg). There were 323 deaths (143 from CVD) and 271 CVD events. The high-biomarker group had a higher risk of mortality than the low-biomarker group (HR, 1.75; 95% CI, 1.37-2.24). The association between BP and outcomes differed between the 2 biomarker groups (P for interaction = 0.01, 0.2, and 0.07 for all-cause mortality, CVD mortality, and first CVD event, respectively). In the low-biomarker group, BP was associated with greater risk of outcomes: HR per 10 mm Hg higher BP was 1.07 (95% CI, 1.01-1.14), 1.10 (95% CI, 0.96-1.25), and 1.04 (95% CI, 0.96-1.13) for all-cause mortality, CVD mortality, and first CVD event, respectively. Importantly, lower BP was not associated with increased risk of outcomes in stratified models, including for those in high biomarker group. Limitations BP measurements not standardized. Conclusions The observed J-shaped association between BP and outcomes in hemodialysis patients is due to confounding by subclinical CVD. A stratification approach based on cTnI and NT-proBNP levels has the potential to inform BP treatment in hemodialysis patients.
AB - Background There is uncertainty regarding treatment of hypertension in hemodialysis patients due to the observed J-shaped association between blood pressure (BP) and death. We hypothesized that this association reflects confounding by cardiovascular disease (CVD) and that stratification by CVD biomarkers, cardiac troponin I (cTnI) and N-terminal fragment of prohormone brain natriuretic peptide (NT-proBNP), might change this association. Study Design National prospective cohort study. Setting & Participants 446 incident hemodialysis patients. Predictor Predialysis systolic BP. Outcomes Mortality (all-cause and CVD) and first CVD event assessed using Cox regression adjusted for demographics, comorbid conditions, and clinical factors. Measurements Participants with cTnI level ≥ 0.1 ng/mL or NT-proBNP level ≥ 9,252 pg/mL were classified as the high-biomarker group; remaining participants were included in the low-biomarker group. Results Participants in the high-biomarker group (n = 138 [31%]) were older (61 vs 57 years) and had a higher prevalence of CVD (67% vs 23%), but similar baseline BPs (152 vs 153 mm Hg). There were 323 deaths (143 from CVD) and 271 CVD events. The high-biomarker group had a higher risk of mortality than the low-biomarker group (HR, 1.75; 95% CI, 1.37-2.24). The association between BP and outcomes differed between the 2 biomarker groups (P for interaction = 0.01, 0.2, and 0.07 for all-cause mortality, CVD mortality, and first CVD event, respectively). In the low-biomarker group, BP was associated with greater risk of outcomes: HR per 10 mm Hg higher BP was 1.07 (95% CI, 1.01-1.14), 1.10 (95% CI, 0.96-1.25), and 1.04 (95% CI, 0.96-1.13) for all-cause mortality, CVD mortality, and first CVD event, respectively. Importantly, lower BP was not associated with increased risk of outcomes in stratified models, including for those in high biomarker group. Limitations BP measurements not standardized. Conclusions The observed J-shaped association between BP and outcomes in hemodialysis patients is due to confounding by subclinical CVD. A stratification approach based on cTnI and NT-proBNP levels has the potential to inform BP treatment in hemodialysis patients.
KW - End-stage renal disease (ESRD)
KW - N-terminal pro-brain natriuretic peptide (NT-proBNP)
KW - dialysis
KW - epidemiology
KW - hemodialysis
KW - hypertension
KW - mortality
KW - outcomes
KW - systolic blood pressure
KW - troponin I
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UR - http://www.scopus.com/inward/citedby.url?scp=84908129333&partnerID=8YFLogxK
U2 - 10.1053/j.ajkd.2014.03.015
DO - 10.1053/j.ajkd.2014.03.015
M3 - Article
C2 - 24787760
AN - SCOPUS:84908129333
VL - 64
SP - 443
EP - 451
JO - American Journal of Kidney Diseases
JF - American Journal of Kidney Diseases
SN - 0272-6386
IS - 3
ER -