Peterson JC, Adler S, Burkart JM, Greene T, Heert LA,
Hunsicker LG et al (MDRD Study Group)
Blood pressure control, proteinuria and the progression
of renal disease
Ann Int Med
(Nov) 123:754-762 1995
The optimal BP control for preventing target organ damage in
hypertension is a major issue in clinical medicine. Likewise,
the optimal BP level for slowing the rate of
progression of any form of renal disease has not been clearly
defined. The modification of diet in renal disease (MDRD) study
was designed to focus on the effect of dietary protein
restriction on progression of renal disease. However, it was
also designed to determine (perhaps more importantly) the effect
of BP control on the progression of renal disease. In this paper,
the authors looked carefully at the relationship between decline
in GFR, proteinuria and achieved BP during follow-up. In this
important analysis of patients with GFR values ranging from 25-55
(Study A) and 13-24 (Study B), the authors found that GFR
declined faster in patients with higher BP levels. More
importantly, they found that in patients with higher grade
proteinuria, lowering mean arterial pressure to < 92 mmHg slowed
the rate of decline in GFR to a significantly greater extent than
lowering mean arterial pressure to 107 mmHg. Importantly, they
found that there was no difference in the decline in GFR in
patients with a baseline urine protein excretion rate < 0.25 g/d
regardless of BP control level. However, their data indicate that
patients with this level of proteinuria have very slow rate of
decline in GFR. This was true in patients in both Study A and B.
Also, they found that lower achieved BP was associated with a
greater and more sustained lowering of proteinuria over time.
Finally, it was shown that lowering proteinuria during the first
4 months of follow-up was associated with a slower rate of
decline in GFR after 4 months of follow-up. These new data in a
large cohort of patients with chronic renal insufficiency are
consistent with the view that proteinuria may be an independent
risk factor for progressive renal disease.
Comment: These findings have
important practice implications for internists and nephrologists.
The data strongly suggest that patients with > 1.0 g/d of
proteinuria should have MAP lowered to the level of 92 mm Hg and
for patients with proteinuria in the range of 0.25 to 1.0 g/day
MAP should be controlled to a level of about 98 mm Hg.
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H: Pathophysiology :
Kidney in hypertension
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