Hypertens Res. 2026 Jun 16. doi: 10.1038/s41440-026-02694-6. Online ahead of print.
ABSTRACT
Blood pressure (BP) control in chronic kidney disease (CKD) remains suboptimal despite renin-angiotensin system (RAS) blockade, contributing to disease progression. This study examined associations of relative aldosterone excess (RAE) with BP control and kidney outcomes in CKD. 745 patients with CKD from the Cardiovascular and Metabolic Disease Etiology Research Center-High Risk (2013-2024) Study were analyzed. BP control status was defined by ambulatory BP: uncontrolled BP (UBP, ≥125/75 mmHg with <3 AHAs or <4 AHAs without diuretics), apparent treatment-resistant hypertension (aTRH, ≥125/75 mmHg with ≥3 AHAs including diuretics or ≥4 AHAs), and controlled BP (CBP, <125/75 mmHg with <4 AHAs). RAE was defined as baseline serum aldosterone ≥ 10 ng/dL with aldosterone to renin ratio ≥30 despite RAS inhibition. The primary kidney outcome was a composite of ≥40% decline in eGFR, new onset eGFR <60 mL/min/1.73 m2, or ESKD. The mean age was 61.5 years, and 53.6% were men. RAE was independently associated with higher odds of uncontrolled hypertension (ABPM ≥ 125/75 mmHg), whereas CBP was associated with lower odds of RAE. Over a median follow-up of 6.9 years, 244 kidney outcomes occurred. In multivariable Cox models, CBP was associated with a reduced risk of kidney outcomes compared to UBP (HR, 0.67; 95% CI, 0.46-0.97), while aTRH was not (HR, 0.88; 95% CI, 0.57-1.37). However, in the interaction model, aTRH with RAE showed a significantly elevated risk of kidney outcomes (HR, 3.04; 95% CI, 1.12-8.24), while the protective effect of CBP was not modified by RAE. Stratified analyses further showed that RAE was associated with the highest risk of kidney outcomes in the aTRH group (HR 2.67, 95% CI 1.2-5.93). Monitoring RAE may help identify high-risk hypertensive CKD patients who could particularly benefit from mineralocorticoid receptor antagonist therapy.
PMID:42304125 | DOI:10.1038/s41440-026-02694-6