Blood pressure stability in hemodialysis patients confers a survival advantage: results from a large retrospective cohort study (original) (raw)
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Kidney International, 2013
It is not clear to what extent changes in blood pressure (BP) during hemodialysis affect or predict survival. Studying comparative outcomes of BP changes during hemodialysis can have major clinical implications including the impact on management strategies in hemodialysis patients. Here we undertook a retrospective cohort study of 113,255 hemodialysis patients over a 5 year period to evaluate an association between change in BP during hemodialysis and mortality. The change in BP was defined as post-minus pre-hemodialysis BP and mean of BP change values during the hemodialysis session was used as a mortality predictor. The patients averaged 61 years old and consisted of 45% women, 32% African-Americans and 58% diabetics. Over a median follow-up of 2.2 years, a total of 53,461 (47.2%) all-cause and 21,548 (25.7%) cardiovascular deaths occurred. In fully adjusted Cox regression model with restricted cubic splines, there was a U-shaped association between change systolic BP and all-cause mortality. Post-dialytic drops in systolic BP between −30 to 0 mmHg were associated with greater survival, but large decreases of systolic BP (more than −30 mmHg) and any increase in systolic BP (over 0 mmHg) were related to increased mortality. Peak survival was found at a change in systolic BP of −14 mmHg. The U-shaped association was also found for cardiovascular mortality. Thus, modest declines in BP after hemodialysis are associated with the greatest survival, whereas any rise or large decline in BP is associated with worsened survival. Park et al. Page 17 † Median (interquartile range) is used for dialysis duration and serum ferritin level. Dialysis duration was defined as the interval from the first dialysis to the entry into cohort. BP was defined as post-HD minus pre-HD BP. Ultrafiltration percentage (%) was calculated as (ultrafiltration per session [kg] / post-HD body weight [kg])*100. Body mass index was calculated using post-HD body weight and height. p-values were estimated by one-way ANOVA, Kruskal-Wallis and Chi square method as appropriate. Conversion factors for units: albumin and hemoglobin in g/dL to g/L, ×10; creatinine in mg/dL to mol/L, ×88.4; calcium in mg/dL to mmol/L, ×0.2495; phosphorus in mg/dL to mmol/L, ×0.3229. No conversion necessary for ferritin in ng/mL and g/L, and white blood cell count in 10 3
Indian Journal of Pharmacy Practice, 2015
Introduction: Hypertension is the second leading cause of End Stage Renal Disease after diabetes mellitus. If hypertension is an etiologically significant cardiovascular risk factor in hemodialysis patients, the first step would be to assess the level of BP accurately. To manage hypertension, limiting dietary fluide intake, and individualizing dialysate sodium delivery would be the initial steps as non pharmacological measures. Therefore as a pharmacological measurement, study was conducted to determine control of blood pressure by anti hypertensive drug treatment. Material And Method: Treatment and control of hypertension was assessed retrospectively in a cohort of 100 clinically stable, adult patients undergoing hemodialysis. Frequency and duration of hemodialysis were also assessed. For quality of life, kidney disease outcomes quality initiative-survey form™ 1.3 health survey was used for 40 adult patients undergoing hemodialysis. Results: Hypertension was documented in patients (n=97) with complicated kidney disease (97.16%) and patients (n=85) with non-complicated kidney disease (85.66%). Hypertension was adequately controlled in only 2.83% (n=3) patients with complicated kidney disease and 14.33% patients (n=15) with non complicated kidney disease undergoing maintainanace hemodialysis. Patients with non-diabetic kidney disease had better quality of life as compared to the patients with diabetic kidney disease. Conclusion: Control of hypertension, particularly systolic hypertension, in patients undergoing hemodialysis for prolong period was inadequate, despite recognition of its prevalence and the use of antihypertensive drugs. Optimizing the use of medications and closer attention to non pharmacological interventions, may improve control of BP.
Multiphasic effects of blood pressure on survival in hemodialysis patients
Kidney International, 2016
Dialysis patients exhibit an inverse, L-or U-shaped association between blood pressure and mortality risk, in contrast to the linear association in the general population. We prospectively studied 9333 hemodialysis patients in France, aiming to analyze associations between predialysis systolic, diastolic, and pulse pressure with all-cause mortality, cardiovascular mortality, and nonfatal cardiovascular endpoints for a median follow-up of 548 days. Blood pressure components were tested against outcomes in time-varying covariate linear and fractional polynomial Cox models. Changes throughout follow-up were analyzed with a joint model including both the timevarying covariate of sequential blood pressure and its slope over time. A U-shaped association of systolic blood pressure was found with all-cause mortality and of both systolic and diastolic blood pressure with cardiovascular mortality. There was an L-shaped association of diastolic blood pressure with all-cause mortality. The lowest hazard ratio of all-cause mortality was observed for a systolic blood pressure of 165 mm Hg, and of cardiovascular mortality for systolic/diastolic pressures of 157/90 mm Hg, substantially higher than currently recommended values for the general population. The 95% lower confidence interval was approximately 135/70 mm Hg. We found no significant correlation for either systolic, diastolic, or pulse pressure with myocardial infarction or nontraumatic amputations, but there were significant positive associations between systolic and pulse pressure with stroke (per 10-mm Hg increase: hazard ratios 1.15, 95% confidence interval 1.07 and 1.23; and 1.20, 1.11 and 1.31, respectively). Thus, whereas high pre-dialysis blood pressure is associated with stroke risk, low pre-dialysis blood pressure may be both harmful and a proxy for comorbid conditions leading to premature death.
Blood pressure targets for hemodialysis patients
Kidney International, 2017
Whereas there is strong relationship between high blood pressure and increased overall and cardiovascular mortality for the general population, observational studies in hemodialysis patients have reported a "U" shaped relationship between pre-hemodialysis blood pressure recordings and patient survival. Previous attempts to introduce pre and post-hemodialysis blood pressure targets were associated with an increased frequency of intra-dialytic hypotension, itself an independent risk factor for mortality. Conversely, meta-analyses of trials of antihypertensive medications in hemodialysis patients, reported survival benefit for those prescribed medication. More recently, further meta-analyses have suggested a reduced risk for cardiovascular mortality benefit with a systolic blood pressures (SBPs) of less than 140 mmHg, the absolute benefit, in terms of risk reduction was greatest in those with the highest vascular disease burden. Even though data from current observational studies and studies of antihypertensive medications would suggest that patient survival would be greater with pre-dialysis SBP should be less than 160 mmHg, there is no current data to propose specific blood pressure targets. Defining blood pressure targets can only be answered by adequately powered prospective randomized controlled trials comparing different targets. As the benefits of lowering blood pressure appear to be greatest for those with most vascular disease, then blood pressure targets may have to be adjusted on an individual risk basis, and future trials should therefore stratify patients according to vascular morbidity and have different targets for patients with differing degrees of pre-existing cardiovascular disease.
Changing Relationship of Blood Pressure with Mortality over Time among Hemodialysis Patients
Journal of the American Society of Nephrology, 2006
High BP is a major risk factor for atherosclerotic cardiovascular disease mortality in the general population. Surprising, studies that have been conducted among hemodialysis (HD) patients have yielded conflicting data on the relationship between BP and mortality. This study explores two hypotheses among HD patients: (1) The relationship between BP and mortality changes over time, and (2) mild to moderate hypertension is well tolerated. Incident HD patients who were treated at Dialysis Clinic Inc. facilities between 1993 and 2003 were studied. Primary end points were atherosclerotic cardiovascular disease and all-cause mortality. The relationship between BP and mortality was analyzed in two sets of Cox proportional hazards models. Model-B explored the relationship between baseline BP and mortality in sequential time periods. Model-TV assessed the relationship between BP, treated as time-varying, and mortality. The study sample (n ؍ 16,959) was similar in characteristics to the United States Renal Data Systems population, although black patients were slightly overrepresented. Model-B demonstrated that the relationship between baseline BP and mortality changes over time. Low systolic BP (<120 mmHg) was associated with increased mortality in years 1 and 2. High systolic BP (>150 mmHg) was associated with increased mortality among patients who survived >3 yr. Low pulse pressure was associated with increased mortality. Model-TV demonstrated that mild to moderate systolic hypertension may be relatively well tolerated. In conclusion, the relationship between baseline BP and mortality changes over time. Mild to moderate systolic hypertension was associated with only modest increases in mortality.
Kidney and Blood Pressure Research, 2012
Background: In incident hemodialysis (HD) patients, the relationship between early systolic blood pressure (SBP) dynamics and mortality is unknown. Methods: Baseline SBP levels were stratified into 5 categories ranging from <120 and ≥180 mm Hg. Early pre-HD SBP change was defined as the slope of pre-HD SBP from week 1 to 12 and categorized in quartiles (Q1, lowest slope). SBP slopes were computed for each patient by simple linear regression. Results: In 3,446 incident HD patients (42% females, 44% black, age 62 ± 15 years), the median pre-HD SBP slope was –1.7 (Q1) to +2.3 (Q4) mm Hg/week. In an adjusted multivariate Cox regression analysis, patients with declining SBP (slope Q1) had higher mortality compared to patients with increasing pre-HD SBP (slope Q4) at 12 months (hazard ratio 2.01, 95% confidence interval 1.35–3.01). In addition, patients with baseline pre-HD SBP <120 mm Hg showed higher mortality compared to the reference group (SBP ≥180 mm Hg) at 12 months (hazard r...
Medicina
Background and Objectives: Hypertension affects at least 80% of hemodialysis patients. Inappropriate control of blood pressure is mentioned as one of the essential cardiovascular risk factors associated with development of cardiovascular events in dialysis populations. The aim of the cross-sectional, retrospective study was the evaluation of the antihypertensive treatment schedule and control of blood pressure in relation to the guidelines in the group of hemodialysis patients. Additionally, we assessed the level of decrease in blood pressure by each group of hypotensive agents. Materials and Methods: 222 patients hemodialyzed in a single Dialysis Unit in three distinct periods of time—2006, 2011, and 2016—with a diagnosis of hypertension were enrolled in the study. The analysis of the antihypertensive treatment was based on the medical files and it consisted of a comparison of the mean blood pressure results reported during the six consecutive hemodialysis sessions. Results: The me...
The Epidemiology of Systolic Blood Pressure and Death Risk in Hemodialysis Patients
American Journal of Kidney Diseases, 2006
Background: This study compares the associations of predialysis systolic blood pressure (SBP) with mortality risk in both incident and prevalent hemodialysis (HD) cohorts by using both conventional and time-varying Cox analyses, thus addressing limitations of prior studies. Methods: A total of 56,338 incident patients starting HD therapy during 1997 to 2001 and 69,590 prevalent HD patients on January 1, 2002, were grouped into the following categories: (1) SBP less than 120 mm Hg, (2) 120 < SBP < 140 mm Hg, (3) 140 < SBP < 160 mm Hg, (4) 160 < SBP < 180 mm Hg, (5) 180 < SBP < 200 mm Hg, and (6) SBP of 200 mm Hg or greater. Conventional and time-varying models evaluated 1-year and 3-year (incident patients only) survival. Results: Nine percent and 26.0% of incident patients and 5.7% and 20.1% of prevalent patients were in categories 1 and 2, respectively. Their associated 1-year hazard ratios (HRs) were 2.63 to 3.68 and 1.57 to 1.68 compared with category 4, the reference group. HRs for categories 3, 5, and 6 were not different from category 4. Time-varying models magnified category 1 and 2 HRs to 5.54 to 7.42 and 1.92 to 2.21, such that 25% to 35% of patients in the target SBP range (<140 mm Hg) had the greatest risk. A "reversed J-shaped" risk profile emerged in the time-varying models, with very high SBP (category 6) associated with HRs of 1.52 to 1.55, but only 1% of patients were in category 6. Three-year outcomes were similar. Conclusion: Epidemiological characteristics of predialysis SBP consistently differ from those in the general population despite different analytic perspectives. The data suggest a need for greater investigative, diagnostic, and therapeutic focus on HD patients with normal and prehypertensive blood pressure ranges. Am J Kidney Dis 48:606-615.