Recent data suggest that visit-to-visit variability of blood pressure (BP) is associated with cardiovascular events. We evaluated the role of BP variability as a determinant of
end-stage renal disease (
ESRD). Using nationally representative data from the Korean National Health Insurance System, 8 199 089 subjects had been enrolled during 2009 to 2010 who were free of
ESRD and underwent ≥3 health examinations during 2005 to 2010 were followed to the end of 2017. BP variability was measured using the coefficient of variation, SD, and variability independent of the mean. The primary outcome was the development of
ESRD, defined as a combination of the relevant disease code and the initiation of
renal replacement therapy. The χ2 test, t test, and log-rank test were used in the statistical analysis. There were 16 567 cases of
ESRD during a median follow-up of 7.89±0.88 years. The highest quartile of systolic or diastolic BP showed a higher incident rate of
ESRD compared with the other 3 quartiles. It was augmented in patients with the highest quartile of both systolic and diastolic BP variabilities. Among patients with the highest quartile of systolic and diastolic BP variabilities, the uncontrolled
hypertension group (>140/90 mm Hg) taking
antihypertensive medication showed the highest incidence rate of
ESRD. These results were consistent when modeling variability of BP using coefficient of variation, SD, and variability independent of the mean and in various sensitivity analyses. Systolic and diastolic BP variabilities were independently associated with an increased incidence of
ESRD, and it was augmented when both variabilities were present together.