Abstract
Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown. Observational study. 17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years. Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to≥160mmHg in 10-mmHg increments) and 5 (<60 to≥90mmHg in 10-mmHg increments) categories, respectively, and as continuous measures. Postdialysis all-cause mortality, assessed over different follow-up periods (ie,<3, 3-<6, 6-<12, and≥12 months after dialysis therapy initiation) using Cox regressions adjusted for demographics, comorbid conditions, medications, cardiovascular medication adherence, body mass index, estimated glomerular filtration rate, and type of vascular access. Mean predialysis SBP and DBP were 141.2±16.1 (SD) and 73.7±10.6mmHg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP<140mmHg. Mortality risks associated with lower SBP were greatest in the first 3 months after dialysis therapy initiation, with multivariable-adjusted HRs of 2.40 (95% CI, 1.96-2.93), 1.99 (95% CI, 1.66-2.40), 1.35 (95% CI, 1.13-1.62), 0.98 (95% CI, 0.78-1.22), and 0.76 (95% CI, 0.57-1.00) for SBP<120, 120 to<130, 130 to<140, 150 to<160, and≥160 (vs 140-<150) mmHg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality. Results cannot be inferred to show causality and may not be generalizable to women or the general US population. Lower predialysis SBP is associated with higher all-cause mortality in the immediate postdialysis period. Predialysis DBP showed no consistent association with postdialysis mortality. Further studies are needed to clarify ideal predialysis SBP levels among incident dialysis patients as a potential means to improve the excessively high early dialysis mortality.
Highlights
Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown
Current clinical guidelines recommend a target BP, 140/90 or,130/80 mm Hg for patients with chronic kidney disease (CKD), depending on their age, severity of albuminuria, and comorbid conditions,[15,16] but there is a paucity of evidence on the association between BP and mortality in patients with advanced non2dialysis-dependent CKD (NDD-CKD), among those in the transition period from advanced NDD-CKD to maintenance dialysis therapy. To address this knowledge gap, we aimed to investigate the associations of systolic BP (SBP) and diastolic BP (DBP) in the predialysis transition period with postdialysis all-cause mortality, using a large nationally representative cohort of US veterans transitioning to dialysis therapy
In this large national cohort of US veterans transitioning to dialysis therapy, we found a reverse J-shaped association of SBP over the 1-year predialysis period with all-cause mortality following dialysis therapy initiation, independent of demographics, comorbid conditions, body mass index (BMI), estimated glomerular filtration rate (eGFR), Figure 1
Summary
To address this knowledge gap, we aimed to investigate the associations of SBP and diastolic BP (DBP) in the predialysis transition period with postdialysis all-cause mortality, using a large nationally representative cohort of US veterans transitioning to dialysis therapy
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