直立性高血压对高血压患者肾脏损害影响的双向队列研究

The impact of orthostatic hypertension on renal damage in patients with hypertension: a bidirectional cohort study

摘要

目的 探讨直立性高血压（OHT）与高血压患者肾功能恶化的关联。方法 采用双向队列研究设计，基于遵义医科大学附属医院高血压门诊数据，纳入2016年1月至2024年5月期间的高血压患者。研究终点包括：①肾功能快速下降（RKFD），定义为随访期间估算的肾小球滤过率（eGFR）较基线每年下降超过5 mL/（min·1.73 m²）；②新发慢性肾脏病（CKD），定义为基线无CKD的受试者在随访期间出现eGFR＜60 mL/（min·1.73 m²）或尿微量白蛋白/肌酐比值（ACR）≥3.0 mg/mmoL，持续超过3个月；③复合肾脏终点事件，即RKFD或新发CKD。终点结果在2024年12月31日之前获得。以标化累积血压、随诊间血压变异性作为随访期间评估患者血压控制情况的指标。采用Kaplan-Meier曲线和多因素Cox回归分析评估OHT对高血压患者肾脏损害的影响。结果 最终队列共纳入856例高血压患者[男性393例（45.91%），OHT患者135例（15.80%）]，平均年龄为（50.0±10.5）岁。中位随访3.75年期间，共有210例（24.53%）患者发生了复合肾脏终点事件，其中171例（19.98%）出现RKFD，62例（7.24%）新发CKD。多因素Cox回归分析结果显示，与体位性血压正常（ONT）者比较，OHT患者发生RKFD、新发CKD的风险均增加（HR=3.03，95%CI：2.16～4.25；HR=3.16，95%CI：1.78～5.62），复合肾脏终点事件风险亦增加（HR=2.81，95%CI：2.06～3.84）。亚组分析显示，OHT与肾脏终点事件的关联在不同年龄、性别、标化累积收缩压及基线eGFR水平中均保持稳定。结论 OHT是高血压患者发生肾功能恶化的独立危险因素。

Abstract

Objective To investigate the association between orthostatic hypertension (OHT) and worsening of renal function in hypertensive patients. Methods From January 2016 to May 2024, a bidirectional cohort was established based on data from the hypertension clinic of the Affiliated Hospital of Zunyi Medical University. The study endpoints included: ① Rapid decline in renal function (RKFD), defined as during the follow-up period, the estimated glomerular filtration rate (eGFR) decreased by more than 5 mL/(min·1.73 m²) per year compared with the baseline. ② New-onset chronic kidney disease (CKD), defined as eGFR＜60 mL/(min·1.73 m²) or urinary microalbumin/creatinine ratio (ACR) ≥3.0 mg/mmol during follow-up for more than 3 months in a subject who did not have chronic kidney disease at baseline. ③ A composite renal endpoint event, defined as a rapid decline in renal function or a new episode of CKD during follow-up. The deadline for the endpoint event was December 31, 2024. Cumulative blood pressure and inter-visit blood pressure variability used as indicators to evaluate the blood pressure control of patients during the follow-up period. Kaplan-Meier curve and multivariate Cox regression analysis were used to investigate the effect of OHT on renal damage in hypertensive patients. Results A total of 856 hypertensive patients (45.91% [393 cases] were male and 15.80% [135 cases] had OHT) were included in the final cohort, with a mean age of (50.0±10.5) years. During a median follow-up of 3.75 years, a total of 210 (24.53%) patients experienced composite renal endpoint events, including 171 (19.98%) with RKFD and 62 (7.24%) with new-onset CKD. Multivariate Cox regression analysis showed that compared with orthostatic normotension (ONT), OHT patients had increased risks of RKFD and new-onset CKD (HR=3.03, 95%CI: 2.16-4.25; HR=3.16, 95%CI: 1.78-5.62), and the risk of composite renal endpoint events also increased (HR=2.81, 95%CI: 2.06-3.84). Subgroup analysis showed that the association between OHT and renal endpoint events remained stable across different ages, sexes, standardized cumulative systolic blood pressure, and baseline eGFR levels. Conclusion OHT is an independent risk factor for worsening renal function in hypertensive patients.

关键词

直立性高血压 / 肾功能恶化 / 危险因素

Key words

orthostatic hypertension / renal function deterioration / risk factors

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基金资助

国家自然科学基金地区基金项目(82460087)

贵州省自然科学基金面上项目(黔科合基础MS（2025）398)