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      Comparison of Ambulatory Blood Pressure Patterns in Patients With Intradialytic Hypertension and Hemodialysis Controls

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          Abstract

          Background/Aims: Intradialytic hypertension (IH) patients have higher mortality risk than other hemodialysis patients and have been shown to have higher ambulatory blood pressure (BP). We hypothesized that interdialytic BP patterns would differ in IH patients and hypertensive hemodialysis controls. Methods: We consecutively screened hemodialysis patients at our university-affiliated units. Based on pre and post-HD BP measurements during the prior 2 week period, we identified IH patients and demographically matched hemodialysis controls. We measured ambulatory interdialytic BP, flow-mediated vasodilation, and intradialytic endothelin-1 (ET-1). Using linear mixed-models, we compared BP slopes during the following intervals: 1-24 hours post-dialysis, 25-44 hours post-dialysis, and 1-44 hours post-dialysis. Results: There were 25 case subjects with IH and 24 controls. Systolic BP during hours 1-44, 1-24, and 25-44 were 143.1 (16.5), 138.0 (21.2), and 150.8 (22.3) mmHg in controls. For IH subjects, they were 155.4 (14.2), 152.7 (22.8), and 156.5 (20.8) mmHg (p=0.008, 0.02, 0.4). In controls, the slopes were +0.6, +0.6, and +0.4 mmHg/hr. In IH subjects, they were +0.1, -0.3, and +0.3 mmHg/hr. The IH 1-24 hour slope differed from the IH 25-44 hour slope (p=0.001) and the control 1-24 hour slope (p=0.002). The change in ET-1 from pre to post dialysis was 0.5 (1.5) pg/mL in controls and 1.0 (2.3) pg/mL in IH patients (p=0.4). In a univariate model, there was an association with screening BP and BP slope (p=0.002 for controls and p=0.1 for IH patients). Conclusions: Interdialytic BP patterns differ in IH patients and hemodialysis controls. The elevated post dialysis blood pressure persists for many hours in IH patients contributing to the overall increased BP burden.

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          Most cited references26

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          Ultrasound assessment of flow-mediated dilation.

          Developed in 1992, the flow-mediated dilation test is now the most commonly used noninvasive assessment of vascular endothelial function in humans. Since its inception, scientists have refined their understanding of the physiology, analysis, and interpretation of this measurement. Recently, a significant growth of knowledge has added to our understanding and implementation of this clinically relevant research methodology. Therefore, this tutorial provides timely insight into recent advances and practical information related to the ultrasonic assessment of vascular endothelial function in humans.
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            The relationship between shear stress and flow-mediated dilatation: implications for the assessment of endothelial function.

            Endothelium-dependent flow-mediated dilatation (FMD) describes the vasodilatory response of a vessel to elevations in blood flow-associated shear stress. Nitric oxide (NO), one of many vasoactive substances released by the endothelium in response to shear stress, is of particular interest to researchers as it is an antiatherogenic molecule, and a reduction in its bioavailability may play a role in the pathogenesis of vascular disease. The goal of many human studies is to create a shear stress stimulus that produces an NO-dependent response in order to use the FMD measurements as an assay of NO bioavailability. The most common non-invasive technique is the 'reactive hyperaemia test' which produces a large, transient shear stress profile and a corresponding FMD. Importantly, not all FMD is NO mediated and the stimulus creation technique is a critical determinant of NO dependence. The purpose of this review is to (1) explain that the mechanisms of FMD depend on the nature of the shear stress stimulus (stimulus response specificity), (2) provide an update to the current guidelines for FMD assessment, and (3) summarize the issues that surround the clinical utility of measuring both NO- and non-NO-mediated FMD. Future research should include (1) the identification and partitioning of mechanisms responsible for FMD in response to various shear stress profiles, (2) investigation of stimulus response specificity in coronary arteries, and (3) investigation of non-NO FMD mechanisms and their connection to the development of vascular disease and occurrence of cardiovascular events.
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              Home blood pressures are of greater prognostic value than hemodialysis unit recordings.

              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
                KBR
                Kidney Blood Press Res
                10.1159/issn.1420-4096
                Kidney and Blood Pressure Research
                S. Karger AG
                1420-4096
                1423-0143
                2016
                June 2016
                22 April 2016
                : 41
                : 3
                : 240-249
                Affiliations
                aDepartment of Internal Medicine, bDepartment of Clinical Sciences, Quantitative Biomedical Research Center, cDepartment of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX; dDepartment of Internal Medicine, University of Washington Medical Center, Seattle, WA; eDepartment of Internal Medicine, Duke University, Durham, MC; fDepartment of Medicine, Quintiles Global Clinical Research Organization, Morrisville, NC, USA
                Author notes
                *Peter Noel Van Buren, MD, Dedman Family Scholar in Clinical Care, University of Texas Southwestern Medical, Center, Department of Internal Medicine, Division of Nephrology, 5939 Harry Hines, Blvd, Dallas, TX 75390-8516 (USA), Tel. 001-214-645-8293, Fax 001-214-645-8903,, E-Mail Peter.vanburen@utsouthwestern.edu
                Article
                443427 Kidney Blood Press Res 2016;41:240-249
                10.1159/000443427
                4919278
                27100207
                98872c93-dd20-43fd-a77b-4ba3109c695b
                © 2016 The Author(s) Published by S. Karger AG, Basel

                This article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND). Usage and distribution for commercial purposes as well as any distribution of modified material requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                : 07 March 2016
                Page count
                Figures: 1, Tables: 3, References: 28, Pages: 10
                Categories
                Original Paper

                Cardiovascular Medicine,Nephrology
                Intradialytic Hypertension,Endothelial Cell Dysfunction,Hemodialysis,Ambulatory Blood Pressure,Hypertension

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