Abstract
Systolic blood pressure variability is an independent risk factor for mortality and cardiovascular events. Standard measures of blood pressure predict outcome poorly in haemodialysis patients. We investigated whether systolic blood pressure variability was associated with mortality in incident haemodialysis patients. We performed a longitudinal observational study of patients commencing haemodialysis between 2005 and 2011 in East Anglia, UK, excluding patients with cardiovascular events within 6 months of starting haemodialysis. The main exposure was variability independent of the mean (VIM) of systolic blood pressure from short-gap, pre-dialysis blood pressure readings between 3 and 6 months after commencing haemodialysis, and the outcome was all-cause mortality. Of 203 patients, 37 (18.2%) patients died during a mean follow-up of 2.0 (SD 1.3) years. The age and sex-adjusted hazard ratio (HR) for mortality was 1.09 (95% confidence interval (CI) 1.02–1.17) for a one-unit increase of VIM. This was not altered by adjustment for diabetes, prior cardiovascular disease and mean systolic blood pressure (HR 1.09, 95% CI 1.02–1.16). Patients with VIM of systolic blood pressure above the median were 2.4 (95% CI 1.17–4.74) times more likely to die during follow-up than those below the median. Results were similar for all measures of blood pressure variability and further adjustment for type of dialysis access, use of antihypertensives and absolute or variability of fluid intake did not alter these findings. Diastolic blood pressure variability showed no association with all cause mortality. Our study shows that variability of systolic blood pressure is a strong and independent predictor of all-cause mortality in incident haemodialysis patients. Further research is needed to understand the mechanism as this may form a therapeutic target or focus for management.
Highlights
Mortality is high among patients undergoing haemodialysis treatment for end-stage renal disease (ESRD), and cardiovascular disease is the main cause of death [1]
We did not include in the analysis 7 patients who died or recovered kidney function and 9 who had cardiovascular events within the first 180 days of haemodialysis
Our study shows that intraindividual visit-to-visit variability of systolic Blood pressure (BP) is associated with all-cause mortality in incident haemodialysis patients, independently of confounders such as age, cardiovascular disease and diabetes
Summary
Mortality is high among patients undergoing haemodialysis treatment for end-stage renal disease (ESRD), and cardiovascular disease is the main cause of death [1]. Blood pressure (BP) variability is more closely associated with adverse outcomes in patients with or at risk of vascular disease than ‘usual’ BP [3] and may play a causal role in the progression of organ damage and in triggering vascular events [4]. Among patients undergoing haemodialysis potential causes of high BP variability such as baroreceptor dysfunction, aortic stiffness and variations in intravascular volume, as well as plausible outcomes such as cerebral small-vessel disease, cerebral haemorrhage and cardiac sudden death are increased compared to the general population [7,8]. Increased BP variability could provide a strong potential explanation for the increased cardiovascular morbidity and mortality among patients undergoing haemodialysis
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