Articles
15 November 1995

Blood Pressure Control, Proteinuria, and the Progression of Renal Disease: The Modification of Diet in Renal Disease Study

Publication: Annals of Internal Medicine
Volume 123, Number 10

Abstract

Objective:

To examine the relations among proteinuria, prescribed and achieved blood pressure, and decline in glomerular filtration rate in the Modification of Diet in Renal Disease Study.

Design:

2 randomized trials in patients with chronic renal diseases of diverse cause.

Setting:

15 outpatient nephrology practices at university hospitals.

Patients:

840 patients, of whom 585 were in study A (glomerular filtration rate, 25 to 55 mL/min·1.73 m2) and 255 were in study B (glomerular filtration rate, 13 to 24 mL/min·1.73 m2). Diabetic patients who required insulin were excluded.

Interventions:

Patients were randomly assigned to a usual blood pressure goal (target mean arterial pressure, less than equals 107 mm Hg for patients less than equals 60 years of age and less than equals 113 mm Hg for patients more than equals 61 years of age) or a low blood pressure goal (target mean arterial pressure, less than equals 92 mm Hg for patients less than equals 60 years of age and less than equals 98 mm Hg for patients more than equals 61 years of age).

Main Outcome Measures:

Rate of decline in glomerular filtration rate and change in proteinuria during follow-up.

Results:

The low blood pressure goal had a greater beneficial effect in persons with higher baseline proteinuria in both study A (P = 0.02) and study B (P = 0.01). Glomerular filtration rate declined faster in patients with higher achieved blood pressure during follow-up in both study A (r = −0.20; P < 0.001) and study B (r = −0.34; P < 0.001), and these correlations were stronger in persons with higher baseline proteinuria (P < 0.001 in study A; P < 0.01 in study B). In study A, the association between decline in glomerular filtration rate and achieved follow-up blood pressure was nonlinear (P = 0.011) and was stronger at higher mean arterial pressure. In both studies, the low blood pressure goal significantly reduced proteinuria during the first 4 months after randomization. This, in turn, correlated with a slower subsequent decline in glomerular filtration rate.

Conclusions:

Our study supports the concept that proteinuria is an independent risk factor for the progression of renal disease. For patients with proteinuria of more than 1 g/d, we suggest a target blood pressure of less than 92 mm Hg (125/75 mm Hg). For patients with proteinuria of 0.25 to 1.0 g/d, a target mean arterial pressure of less than 98 mm Hg (about 130/80 mm Hg) may be advisable. The extent to which lowering blood pressure reduces proteinuria may be a measure of the effectiveness of this therapy in slowing the progression of renal disease.
*For a list of MDRD participants, see reference 10.

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References

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 123Number 1015 November 1995
Pages: 754 - 762

History

Published in issue: 15 November 1995
Published online: 15 August 2000

Keywords

Authors

Affiliations

John C. Peterson, MD
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
Sharon Adler, MD
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
John M. Burkart, MD
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
Tom Greene, PhD
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
Lee A. Hebert, MD
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
Lawrence G. Hunsicker, MD
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
Andrew J. King, MD
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
Saulo Klahr, MD
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
Shaul G. Massry, MD
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
Julian L. Seifter, MD
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
 Modification of Diet in Renal Disease (MDRD) Study Group*
From the Modification of Diet in Renal Disease Study Group, Cleveland, Ohio.
Grant Support: By the National Institute of Diabetes, Digestive and Kidney Diseases and the Health Care Financing Administration.
Corresponding Author: MDRD Study Data Coordinating Center, Department of Biostatistics and Epidemiology, P88, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.
Current Author Addresses: Dr. Peterson: University of Florida, Division of Nephrology, P.O. Box 100224, Gainesville, FL 32610-0224.
Dr. Adler: Harbor-University of California, Los Angeles, Medical Center, Division of Nephrology and Hypertension, 1124 West Carson Street, C-1 Annex, Torrance, CA 90502.
Dr. Burkart: Bowman-Gray School of Medicine, Section of Nephrology, Medical Center Boulevard, Winston-Salem, NC 27157-1053.
Dr. Greene: Department of Biostatistics and Epidemiology, Cleveland Clinic Foundation, 9500 Euclid Avenue, P88, Cleveland, OH 44195.
Dr. Hebert: Ohio State University, Department of Internal Medicine, Nephrology, N210 Means Hall, 1654 Upham Drive, Columbus, OH 43210.
Dr. Hunsicker: University of Iowa Hospitals and Clinics, E300-F General Hospital, Department of Internal Medicine, 200 Hawkins Drive, Iowa City, IA 52242.
Dr. King: New England Medical Center Hospital, Division of Nephrology, Box 148, 750 Washington Street, Boston, MA 02111.
Dr. Klahr: Department of Medicine, The Jewish Hospital of St. Louis, Washington University School of Medicine, 216 South Kingshighway Boulevard, St. Louis, MO 63110.
Dr. Massry: University of Southern California School of Medicine, LACUSC Medical Center, 1200 North State Street, Room 4004, Los Angeles, CA 90033.
Dr. Seifter: Renal Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

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John C. Peterson, Sharon Adler, John M. Burkart, et al. Blood Pressure Control, Proteinuria, and the Progression of Renal Disease: The Modification of Diet in Renal Disease Study. Ann Intern Med.1995;123:754-762. doi:10.7326/0003-4819-123-10-199511150-00003

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