Postdialysis blood pressure rise predicts long-term outcomes in chronic hemodialysis patients: a four-year prospective observational cohort study

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Abstract

Background

The blood pressure (BP) of a proportion of chronic hemodialysis (HD) patients rises after HD. We investigated the influence of postdialysis BP rise on long-term outcomes.

Methods

A total of 115 prevalent HD patients were enrolled. Because of the fluctuating nature of predialysis and postdialysis BP, systolic BP (SBP) and diastolic BP before and after HD were recorded from 25 consecutive HD sessions during a 2-month period. Patients were followed for 4 years or until death or withdrawal.

Results

Kaplan-Meier estimates revealed that patients with average postdialysis SBP rise of more than 5 mmHg were at the highest risk of both cardiovascular and all-cause mortality as compared to those with an average postdialysis SBP change between -5 to 5 mmHg and those with an average postdialysis SBP drop of more than 5 mmHg. Furthermore, multivariate Cox regression analysis indicated that both postdialysis SBP rise of more than 5 mmHg (HR, 3.925 [95% CI, 1.410-10.846], p = 0.008) and high cardiothoracic (CT) ratio of more than 50% (HR, 7.560 [95% CI, 2.048-27.912], p = 0.002) independently predicted all-cause mortality. We also found that patients with an average postdialysis SBP rise were associated with subclinical volume overload, as evidenced by the significantly higher CT ratio ( p = 0.008).

Conclusions

A postdialysis SBP rise in HD patients independently predicted 4-year cardiovascular and all-cause mortality. Considering postdialysis SBP rise was associated with higher CT ratio, intensive evaluation of cardiac and volume status should be performed in patients with postdialysis SBP rise.

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Most cited references 27

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Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study.

Robert N Foley, Charles Herzog, Allan J Collins (2002)

The long-term prognostic associations of pre- and post-dialysis blood pressures, interdialytic weight gain, and antihypertensive use in hemodialysis patients are unclear. The United States Renal Data System (USRDS) Dialysis Morbidity and Mortality Waves 3 and 4 Study, a randomly generated sample of 11,142 subjects receiving hemodialysis on December 31, 1993, was examined, with vital status followed until May 2000. Pre- and post-dialysis blood pressure values, interdialytic weight gain and number of antihypertensives averaged 151.8/79.7, 137.0/74, 3.6% and 0.76, respectively. Prognostic discrimination was maximized by considering pre- and post-systolic and diastolic blood pressure values simultaneously, in a pattern suggesting that wide pulse pressures were associated with mortality (P < 0.0001). Comorbidity adjustment markedly affected associations, with low pre-dialysis diastolic (P < 0.05), low post-dialysis dialysis diastolic pressure (P < 0.05), high post-dialysis dialysis systolic pressure (P < 0.05), and high interdialytic weight gains (P = 0.005) associated with mortality. Each class of antihypertensive drug, except angiotensin-converting enzyme (ACE)-inhibitors, was associated with lower mortality in unadjusted models, an effect most pronounced for beta-blockers (hazards ratio 0.72, 95% CI 0.66 to 0.79, P < 0.0001). Comorbidity adjustment eliminated survival associations for each antihypertensive class except beta-blockers. Pre- and post-dialysis blood pressure values have independent associations with mortality, in a way that implicates wide pulse pressures. Much of the adverse prognosis of wide pulse pressures probably reflects older age and cardiovascular comorbidity. Large interdialytic weight gains are associated with shorter survival when comorbidity is taken into account. Beta-blocker use shows a robust association with survival, and may be protective.

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Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease.

P Barre, Brendan D. Murray, David G. Kent … (1996)

A cohort of 432 ESRD (261 hemodialysis and 171 peritoneal dialysis) patients was followed prospectively for an average of 41 months. Baseline and annual demographic, clinical and echocardiographic assessments were performed, as well as serial clinical and laboratory tests measured monthly while on dialysis therapy. The average mean arterial blood pressure level during dialysis therapy was 101 +/- 11 mm Hg. After adjusting for age, diabetes and ischemic heart disease, as well as hemoglobin and serum albumin levels measured serially, each 10 mm Hg rise in mean arterial blood pressure was independently associated with: the presence of concentric LV hypertrophy (OR 1.48, P = 0.02), the change in LV mass index (beta = 5.4 g/m2, P = 0.027) and cavity volume (beta = 4.3 ml/m2, P = 0.048) on follow-up echocardiography, the development of de novo cardiac failure (RR 1.44, P = 0.007), and the development of de novo ischemic heart disease (RR 1.39, P = 0.05). The association with LV dilation was of borderline statistical significance (OR 1.48, P = 0.06). Mean arterial blood pressures greater than 106 mm Hg were associated with both echocardiographic and clinical endpoints. Paradoxically, low mean arterial blood pressure (RR 1.36 per 10 mm Hg fall, P = 0.009) was independently associated with mortality. The association of low blood pressure with mortality was a marker for having had cardiac failure prior to death. We conclude that even moderate hypertension worsens the echocardiographic and clinical outcome in ESRD patients, especially in those without previous clinical cardiac disease.

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Home blood pressures are of greater prognostic value than hemodialysis unit recordings.

Pooneh Alborzi, Rajiv Agarwal, Nina Patel (2007)

Although ambulatory BP recordings are found to be superior to dialysis unit recordings in predicting outcomes, ambulatory BP are difficult to obtain in the day-to-day treatment of hemodialysis patients. Home BP agree well with ambulatory BP, but the prognostic significance of home BP recordings is unknown in hemodialysis patients. This study ascertained the role of home BP in predicting all-cause and cardiovascular mortality. A prospective cohort study was conducted in 150 patients who were on chronic hemodialysis dialyzing at four university-affiliated units. BP was self-measured at home for 1 wk, for an interdialytic interval by ambulatory recording, and by "routine" and standardized methods in the dialysis unit for 2 wk. Patients were followed for a median of 24 mo to assess the end points of all-cause and cardiovascular mortality. Cardiovascular death occurred in 26 (17%) patients and death in 46 (31%) patients. A 1-SD increase in systolic BP increased the risk for death by 1.35 (95% CI 0.99 to 1.84) and in diastolic BP by 1.40 (95% CI 1.03 to 1.93) for home BP and between 0.97 to 1.19 (P > 0.20) for all-cause mortality for dialysis unit BP recording. A dose-response relationship between increasing quartiles of home BP and all-cause mortality and cardiovascular mortality was seen. Self-measured systolic BP of 125 to 145 mmHg and of 115 to 125 mmHg by ambulatory BP is associated with the best prognosis in hemodialysis patients.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Nephrol

Journal ID (iso-abbrev): BMC Nephrol

Title: BMC Nephrology

Publisher: BioMed Central

ISSN (Electronic): 1471-2369

Publication date Collection: 2012

Publication date (Electronic): 14 March 2012

Volume: 13

Page: 12

Affiliations

[1 ]Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei 11217, Taiwan

[2 ]School of Medicine, National Yang-Ming University, Taipei, Taiwan

Article

Publisher ID: 1471-2369-13-12

DOI: 10.1186/1471-2369-13-12

PMC ID: 3320527

PubMed ID: 22414233

SO-VID: 5b9a0243-f0e6-4c01-837c-55727720d3cb

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Postdialysis blood pressure rise predicts long-term outcomes in chronic hemodialysis patients: a four-year prospective observational cohort study

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Abstract

Background

Methods

Results

Conclusions

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Karger: Nephrology

Most cited references 27

Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study.

Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease.

Home blood pressures are of greater prognostic value than hemodialysis unit recordings.

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