Diastolic Blood Pressure Variability Predicts Cardiovascular Outcomes in CKD, Especially in Advanced Stages

Figure 1. Initial pool definition: all adult patients (age ≥18 years) diagnosed with CKD per KDIGO criteria (eGFR < 60 mL/min/1.73m2 or albuminuria) who completed 24-hour ABPM at the study center during the study period. Exclusion criterion details: incomplete ABPM: defined as < 80% valid readings (eg, monitor dislodgment, insufficient daytime [06:00-22:00] or nighttime [22:00-06:00] recordings). Severe secondary hypertension: confirmed by clinical workup (eg, primary aldosteronism via elevated aldosterone/renin ratio; renal artery stenosis via computed tomography angiography or ultrasound). End-stage renal disease: Patients receiving hemodialysis, peritoneal dialysis, or with a prior kidney transplant at the time of ABPM. Acute cardiovascular events: includes ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, unstable angina, or ischemic/hemorrhagic stroke occurring within 3 months before ABPM. Functional/cognitive impairment: patients unable to wear the ABPM device independently (eg, severe mobility limitation) or with cognitive deficits (eg, dementia) precluding adherence to monitoring protocols. Missing key variables: patients lacking data on…

Figure 2. The associations between DBPV parameters and cardiovascular outcomes in patients with CKD. All HRs are from multivariable Cox regression models adjusted for age, sex, comorbid conditions, kidney function, and medications. Non-dipping pattern was defined as nocturnal DBP decline < 10% per KDIGO guidelines. HR > 1 indicates increased risk, with narrower CIs reflecting higher precision. DBPV, diastolic blood pressure variability; CKD, chronic kidney disease; HR, Hazard ratio.

Figure 3. Hazard ratios of 24 hour DBP SD for all-cause mortality and cardiovascular death across CKD stages (G3a, G3b, and G4-5). Bar chart showing stage-specific risks: in G3a (eGFR 45-59 mL/min/1.73m2), G3b (30-44 mL/min/1.73m2), and G4-5 (<30 mL/min/1.73m2), the HRs for all-cause mortality were 1.05 (95% CI, 1.01-1.09), 1.09 (1.05-1.13), and 1.15 (1.08-1.23), respectively. For cardiovascular death, HRs were 1.07 (1.03-1.11), 1.12 (1.07-1.17), and 1.18 (1.12-1.24). Data were derived from multivariable Cox regression models adjusted for age, sex, BMI, hypertension, diabetes, dyslipidemia, estimated glomerular filtration rate, UPCR, and antihypertensive medications. Error bars represent 95% confidence intervals (not shown in the chart for clarity); P < 0.001 for trend across stages. CKD, chronic kidney disease; DBP SD, DBP SD, diastolic blood pressure standard deviation; eGFR, estimated glomerular filtration rate.

Figure 4. Hazard ratios (HRs) for associations of DBPV and SBPV with adverse cardiovascular outcomes in patients with chronic kidney disease. This forest plot displays the HRs and 95% CIs for 24-hour DBP SD and 24-hour SBP SD in relation to 3 outcomes: all-cause mortality, cardiovascular death, and heart failure hospitalization. Data points represent HRs per 1 mm Hg increase in DBP SD or SBP SD. Horizontal lines indicate 95% CIs. Dashed vertical line denotes HR = 1 (no association). Models: SBPV alone refers to multivariable adjustment for traditional confounders (age, sex, BMI, smoking, diabetes, hypertension, dyslipidemia, eGFR, UPCR, antihypertensive medications, aspirin use, history of cardiovascular disease, and LDL cholesterol) without including DBPV. DBPV + SBPV combined refers to the same multivariable model with both DBPV and SBPV included. P values are shown next to each HR, with P < 0.05 indicating statistical significance. BMI, basic metabolic index, CI, confidence interval; DBPV, diastolic blood pressure variability; DBP SD, diastolic blood pressure standard deviation; eGFR, estimated glomerular filtration rate; LDL; SBPV, systolic blood pressure variability; SBP SD, systolic…

Figure 5. Subgroup analysis showing sex-modified and diabetes-modified associations between 24-hour DBPV standard deviation and cardiovascular outcomes in CKD. The dashed line at HR = 1.0 is the reference for no risk, with error bars indicating 95% confidence intervals. In sex subgroup, DBPV was associated with 10% higher all-cause mortality in men (HR 1.10; 95% CI, 1.04-1.16; P = 0.001) vs 8% in women (HR 1.08; P = 0.009). In diabetes subgroup, DBPV was linked to 14% higher cardiovascular death in patients with diabetes (HR 1.14, 95% CI, 1.07-1.22; P < 0.001) vs 9% in nondiabetics (HR 1.09; P = 0.003). All analyses used multivariable Cox models adjusted for age, eGFR, UPCR, and antihypertensive medications. CKD, chronic kidney disease; DBPV, diastolic blood pressure variability; HR, hazard ratio.

Figure 6. sensitivity analyses for evaluating the robustness of DBPV-prognosis associations in CKD. The dashed line at HR = 1.0 is the reference, with error bars denoting 95% CIs. All analyses showed consistent associations: Original analysis: HR = 1.52 (1.16-1.98; P = 0.002); Excluding missing data: HR = 1.50 (1.15-1.96; P = 0.003); Strict non-dipping: HR = 1.61 (1.23-2.11; P < 0.001); DBP SD tertiles: HR = 1.89 (1.54-2.32; P < 0.001). Analyses used multivariable Cox models adjusted for age, sex, comorbid conditions, and kidney function (n = 1,245). Non-dipping definitions followed KDIGO guidelines. CKD, chronic kidney disease; DBPV, diastolic blood pressure variability; DBP SD, diastolic blood pressure standard deviation; HR, hazard ratio.