Supplementary Material. Serum Chloride is an Independent Predictor of Mortality in Hypertensive Patients
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1 Supplementary Material Serum Chloride is an Independent Predictor of Mortality in Hypertensive Patients Linsay McCallum,* Panniyammakal Jeemon,* Claire E Hastie, Rajan K Patel, Catherine Williamson, Adyani Md Redzuan, Jesse Dawson, William Sloan, Scott Muir, David Morrison, Gordon T. McInnes, Ellen Marie Freel, Matthew Walters, Anna F. Dominiczak, Naveed Sattar, Sandosh Padmanabhan 1
2 Table S1: Characteristics of study population stratified by serum Cl - in quintiles. Variable Cl<=100 Cl= Cl= Cl= Cl>=107 P (N=3085) (N=2670) (N=3228) (N=2508) (N=1477) Value Age at first visit (years), mean (SD) (13.04) (13.90) (14.44) (15.19) <0.001 Men,n (%) 1587 (51.44) 1364 (51.09) 1511 (46.81) 1118 (44.58) 613 (41.50) <0.001 BMI (Kg/m2), mean (SD) (5.05) (5.61) (6.00) (6.01) (6.28) <0.001 (16.40) SBP (mmhg), mean (SD) (30.14) (28.71) (28.76) (29.42) <0.001 (29.42) DBP (mmhg), mean (SD) (16.32) (22.19) (14.76) (14.24) <0.001 (15.22) Total cholesterol (mmol/l), mean (SD) 6.24 (1.35) 6.08 (1.46) 5.93 (1.21) 5.84 (1.22) 5.62 (1.19) <0.001 egfr <60 ml/min per 1.73 m2, n (%) 539 (18.82) 481 (19.13) 532 (17.43) 403 (16.81) 194 (13.72) <0.001 Alcohol use, n (%) 1952 (65.61) 1642 (64.22) 1876 (60.99) 1362 (58.16) 717 (52.64) <0.001 Tobacco use, n (%) 1419 (46.88) 1165 (44.23) 1351 (42.63) 1114 (45.60) 642 (44.93) CVD, n (%) 656 (21.26) 476 (17.83) 527 (16.33) 438 (16.47) 257 (17.40) <0.001 Year of first visit 2
3 First visit <= Year 1987, n (%) 2095 (68.11) 1390 (52.26) 1350 (41.91) 904 (36.06) 465 (31.48) <0.001 First visit between years , 499 (16.22) 705 (26.50) 922 (28.62) 692 (27.60) 309 (20.92) n (%) First visit >= Year 1998, n (%) 482 (15.67) 565 (21.24) 949 (29.46) 911 (36.34) 703 (47.60) Serum Na + (meq/l), mean (SD) (3.20) (2.49) (2.28) (2.23) <0.001 (2.44) Serum K + (meq/l), mean (SD) 3.95 (0.51) 4.08 (0.42) 4.14 (0.43) 4.19 (0.42) 4.24 (0.44) < Serum HCO 3 (meq/l), mean (SD) (3.08) (2.75) (2.78) (2.76) (3.01) <0.001 Anion gap, mean (SD) (3.38) (3.14) (2.95) (2.40) (3.08) <0.001 Diuretic use, n (%) 811 (25.95) 647 (23.79) 657 (19.82) 475 (18.01) 267 (16.50) <0.001 Achieved SBP (mmhg), mean (SD) (25.63) (23.81) (24.07) (22.56) <0.001 (24.80) Achieved DBP (mmhg), mean (SD) (13.77) (12.74) (12.99) (13.19) <0.001 SD=standard deviation, BMI=body mass index, SBP=systolic blood pressure, DBP=diastolic blood pressure, egfr=estimated glomerular filtration rate based on MDRD equation, CVD=prevalent cardiovascular disease at baseline. (12.84) 3
4 Table S2: Characteristics of the study population stratified by serum Cl - and HCO 3 - levels. Cl - <=100 & Cl - >100 & Cl - <=100 & Cl - >100 & Variable HCO 3 - <=25 HCO 3 - <=25 HCO 3 - >25 HCO 3 - >25 P Value (N=692) (N=3693) (N=2003) (N=3681) Age at first visit (years), mean (SD) (13.26) (14.19) (12.18) (13.64) <0.001 Men, n (%) 329 (47.54) 1534 (41.54) 1091 (54.47) 1894 (51.45) <0.001 BMI (Kg/m2), mean (SD) (4.71) (5.55) (4.78) (5.26) <0.001 SBP (mmhg), mean (SD) (31.26) (29.30) (29.79) (28.30) <0.001 DBP (mmhg), mean (SD) (16.83) (15.25) (15.85) (14.57) <0.001 Total cholesterol (mmol/l), mean (SD) 6.40 (1.41) 6.03 (1.28) 6.33 (1.29) 5.99 (1.36) <0.001 egfr <60 ml/min per 1.73 m2, n(%) 174 (27.62) 845 (24.27) 471 (24.45) 762 (21.36) <0.001 Alcohol use, n (%) 464 (68.64) 2720 (63.04) 1316 (67.42) 2248 (62.93) <0.001 Tobacco use, n (%) 334 (48.76) 1736 (47.21) 932 (47.17) 1618 (44.24) 0.02 CVD, n (%) 152 (21.97) 628 (17.01) 443 (22.12) 695 (18.88) <0.001 Year of first visit First visit <= Year 1987, n (%) 495 (71.74) 1984 (53.80) 1538 (76.94) 1985 (54.00) First visit between years , n (%) 150 (21.74) 1353 (36.69) 340 (17.01) 1216 (33.08) 4
5 First visit >= Year 1998, n (%) 45 (6.52) 351 (9.52) 121 (6.05) 475 (12.92) <0.001 Serum Na +, mean (SD) (3.13) (2.32) (2.85) (2.40) <0.001 Serum K +, mean (SD) 4.02 (0.49) 4.14 (0.41) 3.90 (0.49) 4.11 (0.42) Anion gap, mean (SD) (3.05) (2.79) (2.96) (2.71) <0.001 Diuretic use, n (%) 153 (22.01) 801 (21.58) 597 (29.78) 921 (24.95) <0.001 Achieved SBP (mmhg), mean (SD) (26.09) (24.65) (24.45) (23.12) <0.001 Achieved DBP (mmhg), mean (SD) (13.09) (13.07) (13.69) (12.21) <0.001 SD=standard deviation, BMI=body mass index, SBP=systolic blood pressure, DBP=diastolic blood pressure, egfr=estimated glomerular filtration rate based on MDRD equation, CVD=prevalent cardiovascular disease at baseline. 5
6 Table S3: Characteristics of the study population stratified by serum Cl - and Na + levels. Cl - <=100 & Cl - >100 & Cl - <=100 & Cl - >100 & Variable Na + <=135 Na + <=135 Na + >135 Na + >135 (N=430) (N=170) (N=2653) (N=9703) P Value Age at first visit (years), mean (SD) (14.60) (16.93) (12.51) (14.39) <0.001 Men, n (%) 260 (60.47) 116 (68.24) 1236 (46.59) 5154 (53.12) <0.001 BMI (Kg/m2), mean (SD) (5.11) (5.08) (5.04) (5.84) 0.02 SBP (mmhg), mean (SD) (27.75) (30.45) (30.52) (2868) <0.001 DBP (mmhg), mean (SD) (16.33) (15.07) (15.24) (17.13) <0.001 Total cholesterol (mmol/l), mean (SD) 6.18 (1.45) 5.77 (1.50) 6.25 (1.33) 5.87 (1.49) <0.001 egfr <60 ml/min per 1.73 m2, n(%) 116 (28.02) 48 (29.63) 628 (25.35) 2128 (22.97) Alcohol use, n (%) 221 (54.70) 81 (50.94) 1731 (67.35) 5512 (60.12) <0.001 Tobacco use, n (%) 209 (50.12) 71 (44.38) 1210 (46.40) 4194 (44.12) CVD, n (%) 87 (20.23) 33 (19.41) 569 (21.45) 1664 (17.15) <0.001 Year of first visit First visit <= Year 1987, n (%) 177 (41.26) 51 (30.00) 1918 (72.51) 4055 (41.87) First visit between years , n (%) 128 (29.84) 51 (30.00) 370 (13.99) 2576 (26.60) 6
7 First visit >= Year 1998, n (%) 124 (28.90) 68 (40.00) 357 (13.50) 3054 (31.53) <0.001 Serum HCO - 3, mean (SD) (3.11) (3.27) (3.04) (2.89) <0.001 Serum K +, mean (SD) 4.04 (0.57) 4.24 (0.54) 3.94 (0.50) 4.15 (0.43) <0.001 Anion gap, mean (SD) (3.61) (3.61) (3.21) (3.01) <0.001 Diuretic use, n (%) 102 (23.08) 27 (15.00) 709 (26.46) 2019 (19.99) <0.001 Achieved SBP (mmhg), mean (SD) (26.49) (24.69) (25.49) (23.78) <0.001 Achieved DBP (mmhg), mean (SD) (14.13) (13.64) (13.65) (12.73) SD=standard deviation, BMI=body mass index, SBP=systolic blood pressure, DBP=diastolic blood pressure, egfr=estimated glomerular filtration rate based on MDRD equation, CVD=prevalent cardiovascular disease at baseline. 7
8 Table S4: Relationship between serum electrolytes (Spearman correlation coefficient) Variable Serum Na + Serum K + Serum HCO 3 - Serum Na Serum Cl - Anion Gap Serum K (0.041) (0.479)* Serum HCO (<0.001) (<0.001) (<0.001)* (<0.001)* Serum Cl (<0.001) 0.22 (<0.001) (<0.001) (<0.001)* 0.20 (<0.001)* (<0.001)* Anion Gap 0.25 (<0.001) 0.03 (0.008) (<0..001) (<0.001) (<0.001)* 0.04 (<0.333)* (<0.001)* (<0.001)* Values in parenthesis are p values. *Pearson Correlation coefficient and corresponding p values in diuretic users. 8
9 Table S5: Person years of follow-up and mortality event rates stratified by Cl - categories in quintiles. Follow-up and event rates Cl - <=100 Cl - = Cl - = Cl - = Cl - >=107 Total (N=3085) (N=2670) (N=3228) (N=2508) (N=1477) (N=12968) Person years of follow-up (p-y) IHD mortality, n/1000 p-y (95% CI) ( ) ( ) ( ) ( ) ( ) ( ) Stroke mortality, n/1000 p-y (95% CI) ( ) ( ) ( ) ( ) ( ) ( ) CVD mortality, n/1000 p-y (95% CI) ( ) ( ) ( ) ( ) ( ) ( ) Non-CVD mortality, n/1000 p-y (95% CI) ( ) ( ) ( ) ( ) ( ) ( ) All-cause mortality, n/1000 p-y (95% CI) ( ) ( ) ( ) ( ) ( ) ( ) CVD=Cardiovascular disease and IHD=ischemic heart disease. 9
10 Table S6: Cox regression analysis for the association between baseline serum Cl - (single measure at baseline) and mortality. Variable All-cause mortality CVD mortality IHD mortality Stroke Mortality Non-CVD mortality N=3434/11043 N=2019/11043 N=1132/11043 N=485/11043 N=1415/11043 HR 95% CI HR 95% CI HR 95% CI HR 95% CI HR 95% CI Baseline Serum Cl - (Model 1) 0.97* * * * N=3373/9035 N=1993/9035 N=1119/9035 N=477/9035 N=1380/9035 Baseline Serum Cl - (Model 2) 0.98* * * * N=3373/9035 N=1993/9035 N=1119/9035 N=477/9035 N=1380/9035 Baseline Serum Cl - (Model 3) 0.97* * * * Baseline Serum Cl - (Model 4) N=3373/9035 N=1993/9035 N=1119/9035 N=477/9035 N=1380/9035 Serum Cl - <= Serum Cl - = * * * * Serum Cl - = * * * Serum Cl - = * * * * Serum Cl - >= * * Baseline Serum Cl - (Model 5) N=3373/9035 N=1993/9035 N=1119/9035 N=477/9035 N=1380/9035 Serum Cl - <=
11 Serum Cl - = * * * * Serum Cl - = * * * Serum Cl - = * * * * Serum Cl - >= * * *p value <0.05, Model 1 is adjusted for age at first visit, gender, BMI=body mass index, baseline cardiovascular disease, CKD=Chronic kidney disease, tobacco smoking, alcohol use, year of first visit (epochs), SBP=systolic blood pressure, DBP=diastolic blood pressure. Model 2 is adjusted for all variables in model 1 and anion gap. Model 3 is adjusted for all variables in model 1 and serum Na +, serum K + and serum HCO - 3. Model 4 is same as model 3 but the serum chloride was considered as a categorical variable in quintiles. Model 5 is adjusted for all variables in model 4 and stratified for consistent diuretic use in the first five years of follow-up. CVD=Cardiovascular disease and IHD=ischemic heart disease, HR=hazard Ratio, CI=confidence interval. 11
12 Figure S1: Study flow chart 12
13 Figure S2: (A) Kaplan Meier survival curves of serum Cl - in quintiles and all-cause mortality. (B) Kaplan Meier survival curves of Serum Cl - a quintiles and all-cause mortality. adjusted in (A) 13
14 (B) 0.80 Cumulative Incidence log-rank: P<0.001 Q1 Q2 Q3 Q4 Q Number at at risk adjustedchoride_5 AdjCl<=100.0 meq/l = 1 adjustedchoride_5 AdjCl= = 2 adjustedchoride_5 AdjCl== = 3 adjustedchoride_5 AdjCl= = 4 adjustedchoride_5 AdjCl>105.2 meq/l = Follow-up Time (years)
15 Figure S3: ROC curve comparing baseline model and baseline model_chloride for all cause mortality. Conventional model included age, gender, body mass index (BMI), smoking status, systolic blood pressure (SBP), diastolic blood pressure (DBP), alcohol use, egfr as predictors 15
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