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      The relationship between intradialytic hypotension and vascular calcification in hemodialysis patients

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          Abstract

          Background

          Vascular calcification is associated with structural and functional abnormality of the heart and blood vessels. We investigated the relationship between intradialytic hypotension (IDH) and vascular calcification in hemodialysis (HD) patients, and their impacts on cardiovascular events (CVEs).

          Method

          We enrolled 191 maintenance HD patients who underwent plain abdomen radiography for abdominal aortic calcification score (AACS). A nadir systolic blood pressure (BP) < 90 mm Hg or the requirement of bolus fluid administration was required to quantify the hypotension diagnosis. IDH was defined as > 2 hypotension episodes during 10 HD treatments.

          Results

          Among the 191 patients, IDH occurred in 32. AACS was higher in the IDH group compared with the no-IDH group (8.4 ± 6.0 vs. 4.9 ± 5.2, respectively; P = 0.001). High AACS was an independent risk factor after adjustment for age, diabetes mellitus, ultrafiltration, diastolic BP, and calcium level (odds ratio (OR) = 1.09, 95% CI = 1.01–1.18; P = 0.03). Patients with both IDH and AACS ≧ 4 had the highest cumulative CVE rate (27.9%, P = 0.008) compared with 11.2%, 12.5%, and 6% for those with AACS ≧ 4 only, with IDH only, and neither, respectively. In multivariate analysis, the presence of both IDH and AACS ≧ 4 was a significant predictor of CVE (hazard ratio (HR) = 2.84, 95% CI = 1.04–7.74, P = 0.04).

          Conclusion

          IDH is associated with abdominal aortic calcification and is an independent risk factor for IDH. Both IDH and high AACS were significant predictors of CVE.

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          Most cited references20

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          New indices to classify location, severity and progression of calcific lesions in the abdominal aorta: a 25-year follow-up study.

          L Kauppila (1997)
          The purpose of the present study was to assess the location, severity and progression of radiopaque lumbar aortic calcifications and to evaluate the utility of summary scores of lumbar calcification in a population-based cohort. Lateral lumbar films, obtained in 617 Framingham heart study participants, were analysed for the presence of abdominal aortic wall calcification in the region corresponding to the first through fourth lumbar vertebrae. The severity of the anterior and posterior aortic calcification were graded individually on a 0-3 scale for each lumbar segment and the results were summarized to develop four different composite scores: (1) affected segments score (range 0-4); (2) anterior and posterior affected score (range 0-8); and (3) antero-posterior severity score (range 0-24). The prevalence of aortic calcification was 37% in men and 27% in women at baseline and 86% in both genders at the follow-up exam 25 years later. During the follow-up interval, the mean of the affected segments score increased from 0.7 in men (0.5 in women) to 2.7 (2.8 in women), the mean of the anterior and posterior affected score from 1.2 (0.8 in women) (P = 0.012 for difference between genders) and the mean of the antero-posterior severity score increased from 1.5 (1.3 in women) to 9.3 (10.3 in women). The antero-posterior severity score offered a slight advantage over other composite scores and had the highest inter-rater intra-class correlations. In summary, lumbar aortic calcification can be graded and composite summary scores are reproducible. This technique appears to provide a simple, low cost assessment of subclinical vascular disease.
          Article 0 comments Cited 199 times – based on 0 reviews     Review now
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            Hemodialysis-associated hypotension as an independent risk factor for two-year mortality in hemodialysis patients.

            Tatsuya Shoji, M Fujii, Yoshiharu Tsubakihara … (2004)
            The relationship between blood pressure (BP) and mortality in hemodialysis patients has remained controversial. Some studies suggested that a lower pre- or postdialysis BP was associated with excess mortality, while others showed poorer outcome in patients with uncontrolled hypertension. We conducted a multicenter prospective cohort study to evaluate the impact of hemodialysis-associated hypotension on mortality. We recruited 1244 patients (685 males; mean age, 60 +/- 13 years) who underwent hemodialysis in 28 units during the two-year study period beginning in December 1999. Pre-, intra-, and postdialysis BP, and BP upon standing soon after hemodialysis, were measured in all patients at entry. Logistic regression analysis was used to assess the effect on mortality of pre-, intra-, and postdialysis BP, a fall in BP during hemodialysis, and a fall in BP upon standing soon after hemodialysis. During the study period, 149 patients died. Logistic models identified the lowest intradialysis systolic blood pressure (SBP) and degree of fall in SBP upon standing soon after hemodialysis as significant factors affecting mortality, but not pre- or postdialysis SBP and diastolic BP. The adjusted odds ratio for death was 0.79 (95% CI 0.64-0.98) when the lowest intradialysis SBP was analyzed in increments of 20 mm Hg, and was 0.82 (95% CI 0.67-0.98) when the fall in SBP upon standing soon after hemodialysis was analyzed in increments of 10 mm Hg. These results suggest that intradialysis hypotension and orthostatic hypotension after hemodialysis are significant and independent factors affecting mortality in hemodialysis patients.
            Article 0 comments Cited 171 times – based on 0 reviews     Review now
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              Arterial stiffening and vascular calcifications in end-stage renal disease.

              A P Guerin, G. M. London, S. Marchais … (2000)
              Epidemiological studies have identified aortic stiffness as an independent predictor of cardiovascular mortality in end-stage renal disease (ESRD) patients. In these patients, aortic pulse wave velocity (PWV) was associated with mediacalcosis, but the influence of arterial calcifications on the viscoelastic properties of large arteries was not well characterized. The purpose of the present study was to analyse the influence of arterial calcifications on arterial stiffness in stable haemodialysed patients. We studied 120 stable ESRD patients on haemodialysis. All patients underwent B-mode ultrasonography of common carotid artery (CCA), aorta, and femoral arteries to determine CCA distensibility, the elastic incremental modulus (Einc), and the presence of vascular calcifications. All patients underwent measurement of aortic PWV and echocardiogram. The presence of calcifications was analysed semiquantitatively as a score (0 to 4) according to the number of arterial sites with calcifications. Our observations indicate that arterial and aortic stiffness is significantly influenced by the presence and extent of arterial calcifications. The extent of arterial calcifications is in part responsible for increased left ventricular afterload, and is inversely correlated with stroke volume. The influence of calcifications is independent of the role of ageing and blood pressure. Arterial calcifications density increases with age, duration of haemodialysis, the fibrinogen level, and the prescribed dose of calcium-based phosphate binders. The results of this study showed that the presence of vascular calcifications in ESRD patients was associated with increased stiffness of large capacity, elastic-type arteries, like the aorta and CCA. The extent of arterial calcifications increased with the use of calcium-based phosphate-binders.
              Article 0 comments Cited 166 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                AJin Cho:
                ORCID: http://orcid.org/0000-0001-7097-7026
                Role: Data curationRole: Formal analysisRole: Writing – original draftRole: Writing – review & editing
                Young-Ki Lee: Role: ConceptualizationRole: Data curationRole: Formal analysis
                Jieun Oh: Role: ConceptualizationRole: Funding acquisitionRole: SupervisionRole: Validation
                Jong-Woo Yoon: Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: Supervision
                Dong Ho Shin: Role: ConceptualizationRole: Data curationRole: MethodologyRole: Resources
                Hee Jung Jeon: Role: Data curationRole: Resources
                Myung-Jin Choi: Role: ConceptualizationRole: Data curationRole: Resources
                Jung-Woo Noh: Role: Data curationRole: Resources
                Abelardo I. Aguilera: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 19 October 2017
                Publication date Collection: 2017
                Volume: 12
                Issue: 10
                Electronic Location Identifier: e0185846
                Affiliations
                [1 ] Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University, Hallym University College of Medicine, Seoul, Korea
                [2 ] Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
                [3 ] Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Korea
                Hospital Universitario de la Princesa, SPAIN
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0001-7097-7026
                Article
                Publisher ID: PONE-D-17-16212
                DOI: 10.1371/journal.pone.0185846
                PMC ID: 5648120
                PubMed ID: 29049308
                SO-VID: 05d60b74-0384-4d9e-b084-c32128738593
                Copyright © © 2017 Cho et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 27 April 2017
                Date accepted : 20 September 2017
                Page count
                Figures: 1, Tables: 4, Pages: 9
                Funding
                Funded by: Hallym Research Fund 2014
                Award ID: HURF-2014-09
                Award Recipient :
                ORCID: http://orcid.org/0000-0001-7097-7026
                This work was supported by a grant from the Kyowa Kakko Kirin, Korea Co. Ltd. (2014–2016).
                Categories
                Subject: Research Article
                Subject: Biology and Life Sciences
                Subject: Physiology
                Subject: Physiological Processes
                Subject: Calcification
                Subject: Medicine and Health Sciences
                Subject: Physiology
                Subject: Physiological Processes
                Subject: Calcification
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Blood Pressure
                Subject: Hypotension
                Subject: Medicine and Health Sciences
                Subject: Nephrology
                Subject: Medical Dialysis
                Subject: Medicine and Health Sciences
                Subject: Endocrinology
                Subject: Endocrine Disorders
                Subject: Diabetes Mellitus
                Subject: Medicine and Health Sciences
                Subject: Metabolic Disorders
                Subject: Diabetes Mellitus
                Subject: Research and Analysis Methods
                Subject: Separation Processes
                Subject: Filtration
                Subject: Ultrafiltration
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Blood Pressure
                Subject: Biology and Life Sciences
                Subject: Biophysics
                Subject: Ion Channels
                Subject: Calcium Channels
                Subject: Physical Sciences
                Subject: Physics
                Subject: Biophysics
                Subject: Ion Channels
                Subject: Calcium Channels
                Subject: Biology and Life Sciences
                Subject: Physiology
                Subject: Electrophysiology
                Subject: Ion Channels
                Subject: Calcium Channels
                Subject: Medicine and Health Sciences
                Subject: Physiology
                Subject: Electrophysiology
                Subject: Ion Channels
                Subject: Calcium Channels
                Subject: Biology and Life Sciences
                Subject: Physiology
                Subject: Electrophysiology
                Subject: Neurophysiology
                Subject: Ion Channels
                Subject: Calcium Channels
                Subject: Medicine and Health Sciences
                Subject: Physiology
                Subject: Electrophysiology
                Subject: Neurophysiology
                Subject: Ion Channels
                Subject: Calcium Channels
                Subject: Biology and Life Sciences
                Subject: Neuroscience
                Subject: Neurophysiology
                Subject: Ion Channels
                Subject: Calcium Channels
                Subject: Biology and Life Sciences
                Subject: Biochemistry
                Subject: Proteins
                Subject: Ion Channels
                Subject: Calcium Channels
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Coronary Heart Disease
                Subject: Medicine and Health Sciences
                Subject: Cardiology
                Subject: Coronary Heart Disease
                Custom metadata
                Data Availability All relevant data are within the paper and its Supporting Information files.

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