Antihypertensive Treatment Patterns in CKD Stages 3 and 4: The CKD-REIN Cohort Study

IF 3.2 Q1 UROLOGY & NEPHROLOGY
Margaux Costes-Albrespic , Sophie Liabeuf , Solène Laville , Christian Jacquelinet , Christian Combe , Denis Fouque , Maurice Laville , Luc Frimat , Roberto Pecoits-Filho , Oriane Lambert , Ziad A. Massy , Bénédicte Sautenet , Natalia Alencar de Pinho
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引用次数: 0

Abstract

Rationale & Objective

Blood pressure (BP) control is essential for preventing cardiorenal complications in chronic kidney disease (CKD), but most patients fail to reach BP target. We assessed longitudinal patterns of antihypertensive drug prescription and systolic BP.

Study Design

Prospective observational cohort study.

Setting & Population

In total, 2,755 hypertensive patients with CKD stages 3-4, receiving care from a nephrologist, from the French CKD–Renal Epidemiology and Information Network (CKD-REIN cohort study).

Exposure

Patient factors, including sociodemographic characteristics, medical history, and laboratory data, and provider factors, including number of primary care physician and specialist encounters.

Outcomes

Changes in antihypertensive drug-class prescription during follow-up: add-on or withdrawal.

Analytical Approach

Hierarchical shared-frailty models to estimate hazard ratios (HR) to deal with clustering at the nephrologist level and linear mixed models to describe systolic BP trajectory.

Results

At baseline, median age was 69 years, and mean estimated glomerular filtration rate was 33 mL/min/1.73 m². In total, 66% of patients were men, 81% had BP  130/80 mm Hg, and 75% were prescribed ≥2 antihypertensive drugs. During a median 5-year follow-up, the rate of changes of antihypertensive prescription was 50 per 100 person-years, 23 per 100 for add-ons, and 25 per 100 for withdrawals. After adjusting for risk factors, systolic BP, and the number of antihypertensive drugs, poor medication adherence was associated with increased HR for add-on (1.35, 95% confidence interval [CI], 1.01-1.80), whereas a lower education level was associated with increased HR for withdrawal (1.23, 95% CI, 1.02-1.49) for 9-11 years versus ≥12 years. More frequent nephrologist visits (≥4 vs none) were associated with higher HRs of add-on and withdrawal (1.52, 95% CI, 1.06-2.18; 1.57, 95% CI, 1.12-2.19, respectively), whereas associations with visit frequency to other physicians varied with their specialty. Mean systolic BP decreased by 4 mm Hg following drug add-on but tended to increase thereafter.

Limitations

Lack of information on prescriber and drug dosing.

Conclusions

In patients with CKD and poor BP control, changes in antihypertensive drug prescriptions are common and relate to clinician preferences and patients’ tolerability. Sustainable reduction in systolic BP after add-on of a drug class is infrequently achieved.

Plain-Language Summary

Blood pressure (BP) control remains unattained in most patients with chronic kidney disease (CKD), raising questions about how antihypertensive treatment is managed. Our study highlights dynamic, yet heterogeneous patterns of antihypertensive drug prescriptions in patients with CKD stages 3-4 receiving care from a nephrologist over 5 years of follow-up. Modifiable factors such as high body mass index and poor medication adherence were associated with higher hazard of adding-on an antihypertensive drug class, independently of baseline BP and antihypertensive treatment. Similarly, lower education level was associated with antihypertensive drug withdrawn, as was more frequent visits to primary care physicians, underlining the importance of coordinated care. Sustainable reduction in systolic BP after add-on of a drug class is infrequently achieved and may be related to drug withdrawal and poor treatment adherence.
CKD 3 期和 4 期患者的抗高血压治疗模式:CKD-REIN 队列研究
研究理由和目的控制血压对于预防慢性肾脏病(CKD)的心肾并发症至关重要,但大多数患者无法达到血压目标。我们对降压药处方和收缩压的纵向模式进行了评估。研究设计前瞻性观察性队列研究。暴露患者因素包括社会人口学特征、病史和实验室数据,医疗服务提供者因素包括初级保健医生和专科医生接诊次数。结果随访期间降压药类处方的变化:加服或停用。分析方法分层共享虚弱模型估算危险比(HR),以处理肾病医生层面的聚类问题,线性混合模型描述收缩压轨迹。结果基线时,中位年龄为 69 岁,平均肾小球滤过率为 33 mL/min/1.73 m²。66%的患者为男性,81%的患者血压≥130/80 mm Hg,75%的患者服用≥2种降压药。在中位 5 年的随访期间,降压药处方的变化率为每 100 人年 50 次,其中 23 次为加药,25 次为停药。在对危险因素、收缩压和降压药物数量进行调整后,用药依从性差与加药 HR 的增加有关(1.35,95% 置信区间 [CI],1.01-1.80),而教育水平较低与 9-11 年与≥12 年的停药 HR 的增加有关(1.23,95% CI,1.02-1.49)。肾科医生就诊次数越多(≥4 次与无次数),加药和停药的 HR 越高(分别为 1.52,95% CI,1.06-2.18;1.57,95% CI,1.12-2.19),而与其他医生就诊次数的关系则因专科而异。结论 在血压控制不佳的慢性肾脏病患者中,抗高血压药物处方的改变很常见,这与临床医生的偏好和患者的耐受性有关。白话摘要大多数慢性肾脏病(CKD)患者仍无法达到血压控制目标,这就提出了如何管理降压治疗的问题。我们的研究强调了在 5 年的随访中,接受肾科医生治疗的 CKD 3-4 期患者降压药处方的动态但异质性模式。高体重指数和用药依从性差等可改变因素与增加抗高血压药物种类的较高风险有关,与基线血压和抗高血压治疗无关。同样,较低的教育水平与停用降压药有关,更频繁地就诊于初级保健医生也与停用降压药有关,这凸显了协调护理的重要性。添加一类药物后收缩压持续降低的情况并不多见,这可能与停药和治疗依从性差有关。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Kidney Medicine
Kidney Medicine Medicine-Internal Medicine
CiteScore
4.80
自引率
5.10%
发文量
176
审稿时长
12 weeks
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