Postdialysis BP Research Articles

Apparently Resistant Hypertension in Polish Hemodialyzed Population: Prevalence and Risk Factors.

The aim of this study was to assess the prevalence, characteristics, and determinants of apparent treatment-resistant hypertension (aTRH) in an unselected large population of patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) throughout the country. A database of 5879 patients (mean age 65.2 ± 14.2 years, 60% of males receiving hemodialysis) was obtained from the biggest provider of hemodialysis in the country. Hypertension and aTRH were defined using pre- or/and post-dialysis BP values. Patients with and without aTRH (non-aTRH) were compared. Using pre- and post-dialysis criteria, hypertension was diagnosed in 90.7% and 89.1% of subjects, respectively. According to pre- and post-dialysis blood pressure criteria, aTRH incidences were 40.9% and 38.4%, respectively. The hypertensive patients with aTRH versus non-aTRH were younger, had a higher rate of cardiovascular disease, lower dialysis vintage, shorter time on dialysis, higher eKt/V, higher ultrafiltration, higher pre- and post-dialysis BP and HR, and higher use of antihypertensive drugs. Factors that increase the risk of aTRH according to both pre- and post-dialysis BP criteria were age-OR 0.99 [0.98-0.99] and 0.99 [0.98-0.99], the history of CVD 1.26 [1.08-1.46] and 1.30 [1.12-1.51], and diabetes 1.26 [1.08-1.47] and 1.28 [1.09-1.49], adjusted OR with 95% CI. In the real-life world, as much as 40% of HD patients may have aTRH. In ESKD HD patients, aTRH seems to be multifactorial, influenced by patient-related rather than dialysis-related factors. Various definitions of aTRH preclude easy comparisons between studies.

#2871 BRAIN NATRIURETIC PEPTIDE LEVEL IN CHRONIC EGYPTIAN HEMODIALYSIS PATIENTS: ITS RELATION TO VENTRICULAR FUNCTION AND VOLUME STATUS

Abstract Background and Aims Volume overload is major problem in chronic hemodialysis patient and BNP level is related to volume status of the patient . Aims To assess BNP level in hemodialysis patient before and after HD session and to study its role as a marker for volume overload in hemodialysis patient depending on clinical findings and echocardiography parametershemodialysis. Method The study was conducted on 50 patients of Nephrology and hemodialysis unit, Mansoura University Hospital. Our patients were classified according to left ventricular mass index (LVMI) into patients with left ventricular hypertrophy (LVH)(35 patients) and patients without LVH (15 patients). We classified our patients into another two groups according to predialysis BNP level to group with BNP level˃100pg/ml(33 patients) which was associated with cardiac dysfunction and group with BNP level˂100pg/ml (17 patients). Results In the present study, the median of pre-dialysis BNP level was 126 pg/ml and the median of post- dialysis BNP was 25 pg/ml, this demonstrate that BNP plasma level decline after the hemodialysis session. Among The studied patients, the mean of predialysis systolic BP in patients with high BNP level ˃100 pg/ml is (155.65) higher than patients with low BNP level˂100 pg/ml . The incidence of lower limb edema, congested neck veins and chest crepitations was high in the group with BNP level (˃100 pg/ml) when compared with BNP level (<100 pg/ml). In the present study, according to ROC curve, predialysis BNP level may be a marker for lower limb edema with cutoff point (140.8) pg/ml with (85%) sensitivity and (77%) specificity and shows that the best cutoff point of predialysis BNP level in prediction of neck veins is (40.4) pg/ml with (94%) sensitivity and(28%) specificity and shows that the best cutoff point of predialysis BNP level in prediction of chest crepitation is (42.8) with (82%) sensitivity and (30%) specificity . Conclusion In Egyptian hempodialysis patients, there is a negative correlation between BNP predialysis and weight pre and post dialysis.There is significant correlation between BNP postdialysis and systoilc BP predialysis, RVD and COP. There is signifcant correlation between delta BNP and systoilc BP predialysis and ultrafiltration volume.

BLOOD PRESSURE MONITORING IN HEMODIALYSIS PATIENTS: ARE IMPRECISE THE MEASURING PRE- AND POSTDIALYSIS OR INTERDIALYTIC AMBULATORY BP?

Objective: The optimal Blood Pressure in Hemodialysis are still unclear as to their value or measurement time and better hypotensive treatment. Some authors recommend BP < 140/90 mmHg and < 130/80 mmHg before and after HD respectively. There are an associations between predialysis systolic, diastolic and pulse pressure with all-cause mortality. Our objective is to assess the percentage of hypertensive patients in our hemodialysis unit after adjusting their dry weight and there is a difference between the pre and postdialysis blood pressure measurement. Design and method: We included 66 patients(N 66) hemodialysis unit, we have performed standardized BP measurements among hemodialysis patients, predialysis SBP/DBP, postdialysis SBP/DBP, pulse pressure and interdialytic BP assessed by ambulatory. Patients characteristics: (male [n 36] 54,5%), median age 68 yrs (R 29–90y), DM 25 patients (37,8%),nontraumatic amputation 10 patients (15%). Results: Predialysis SBP/DBP values >140/90 mmHg was 50% (33 patients), 51,5% female. Predialysis Pulse pressure 82 mmHg Postdialysis SBP/DBP values > 140/90 mmHg was 59% (39 patients), 54% female. Postdialysis Pulse pressure 83 mmHg Interdialytic BP value > 140/90 mmHg was 50% (30 patients) and Pulse pressure 78 mmHg Group HT:DM 17 patients(52%) nontraumatic amputation 8 patients(24%) Group NO HT:DM 8 patients(24%) nontraumatic amputation 2 patients(6%) (TABLE 1) Conclusions: Until the actuality there is no optimal criteria of BP in hemodialysis patients, or when it should be measured pre or postdialysis. In our study, we do not see a difference between BP Predialysis, Postdialysis or Interdialytic BP. Also we see in group HT, there are more diabetics and more nontrauamtic amputation but there is no significant difference between both groups, possibly for being a small sample

Opinion on the (Hemo)dialysate Sodium Prescription: Dialysate Sodium Prescription Should Not Be Considered in Isolation

With advances in hemodialysis technology and the desire to achieve cardiovascular stability during dialysis, prescribed dialysate sodium concentration has gradually increased over the years. Short-term trials suggest low dialysate sodium (<138 mEq/L) is beneficial in reducing interdialytic weight gain, pre- and post-dialysis BP, and predialysis serum sodium; but it increases intradialytic hypotensive episodes. We believe dialysate sodium prescription cannot be considered in isolation. Our approach is to use patient symptoms, meticulous fluid volume management and low temperature dialysate in conjunction with neutral dialysate sodium in managing our dialysis patients. Long-term trials are needed to inform optimum dialysate sodium prescription.

MO108ACCURACY OF PERIDIALYTIC, INTRADIALYTIC AND SCHEDULED INTERDIALYTIC RECORDINGS FOR DIAGNOSING HIGH AMBULATORY BLOOD PRESSURE IN HEMODIALYSIS

Abstract Background and Aims Hypertension is highly prevalent in hemodialysis patients. Current recommendations suggest the use of ambulatory-BP-monitoring (ABPM) as the gold-standard for hypertension diagnosis and management in these subjects. This study assessed the accuracy of peridialytic, intradialytic and scheduled interdialytic recordings in diagnosing high 44-h interdialytic BP. Method A total of 242 hemodialysis patients that underwent valid 48-h ABPM were included in the analysis. We used ambulatory BP as reference standard and tested the accuracy of the following BP metrics: Pre- and post-dialysis, Intradialytic, Intradialytic plus pre/post-dialysis readings and Scheduled interdialytic BP (out-of-dialysis day: readings at 8:00 am, 8:00 pm or their average). Results 44-h SBP/DBP levels had significant differences with and pre- or post-dialysis BP, but no or minor differences with any of the other BP metrics. 44-h SBP and DBP correlated strongly with Intradialytic (r=0.713/0.753, p<0.001), Intradialytic plus pre/post-dialysis (r=0.725/0.758, p<0.001) and averaged Scheduled interdialytic BP (r=0.874/0.823, p<0.001). Bland-Altman plots showed absence of systemic bias for all index metrics, but large between-method difference and wider 95% limits of agreement for pre- and post-dialysis BP compared to Intradialytic, Intradialytic plus pre/post-dialysis and averaged Scheduled interdialytic BP. In ROC-analysis for diagnosing 44-h SBP≥130mmHg, the Area-Under-the-Curve of pre-dialysis (0.723) and post-dialysis SBP (0.746) were significantly lower than that of Intradialytic (0.850), Intradialytic plus pre/post-dialysis (0.850) and Scheduled interdialytic SBP (0.917) (z-test, p<0.001 for all pairwise comparisons). The corresponding sensitivity/specificity values were 76.6%/54.5%, 78.7%/59.4%, 73.0%/81.2%, 68.1%/88.1% and 82.3%/89.1%, respectively. Similar observations were made for DBP. Conclusion In contrast to pre- and post-dialysis BP, the average of intradialytic, intradialytic plus pre/post-dialysis or scheduled interdialytic BP recordings show reasonable agreement with ambulatory BP and may be used for hypertension diagnosis and management in hemodialysis.

Effect of Fluid Management Guided by Bioimpedance Spectroscopy on Cardiovascular Parameters inHigh Risk Hemodialysis Patients

Abstract Introduction One of the greatest challenges for physicians caring for hemodialysis (HD) patients is assessing their extracellular fluid volume (ECFV), so different strategies have been investigated to aid in this evaluation. The clinical examination, biochemical markers of volume overload, Inferior vena cava ultrasound, lung ultrasound, Continuous blood volume monitoring (CBVM) and Bio impedance measurement of intra- and extracellular water (ECW). Aim Aim of the present study is to evaluate the effect of fluid management guided by bio impedance spectroscopy on CV parameters and BP in high risk HD patients. Patients and Methods This is a prospective interventional one year study. Fifty (50) maintenance HD patients have been recruited from Nasr City Insurance Hospital dialysis centre, the study population divided into two groups followed over (12) months, the groups were classified as follows: Intervention group (high risk group) included (25) CV compromised HD patients. (FO pre (L)) was assessed by BIS monthly before dialysis session. Control Group (low risk group) included (25) clinically stable HD patients. Dry weight was assessed clinically in the control group. Results Statistically significant decline in pre& post-dialysis systolic BP, the rate of use of BB & ACEI drugs& the rate of IDH in the intervention group. FO pre (L), TAFO (L), IDWG (L),post-dialysis weight (Kg), but in intergroup analysis, however it became evident that pre FO (L), TAFO (L), IDWG (L) and post-dialysis weight (Kg) decrease in the intervention group was significantly higher than the control group. (LVMI, LVIDD, RVDD and left atrium volume) values assessed by Echo showed a statistically significant decline in the two groups, however in intergroup analysis; it became evident that (LVMI, LVIDD and RVDD) values and left atria volume decrease in the intervention group were significantly higher than the control group. Conclusion Assessment of fluid overload with bio-impedance spectroscopy is a helpful tool beside clinical examination to better recognize hidden fluid overload which leads to significant improvement in the CV status of high risk HD patients.

Comparison of characteristics of centers practicing incremental vs. conventional approaches to hemodialysis delivery - postdialysis recovery time and patient survival.

Conventional haemodialysis (HD) involves treatment times of around 4 hours thrice weekly, taking no account of residual kidney function (RKF). In incremental HD the frequency and duration of dialysis sessions are individualized according to RKF. There are no studies comparing these approaches. We utilized data from a recent multicenter study to compare patient characteristics and outcomes between a center practicing incremental HD and others using a conventional approach. Seven hundred and nine patients attending for routine outpatient HD in five UK centers were studied. One center practiced incremental dialysis (n = 254) and four conventional HD (n = 455). Data collected included demographics, comorbidity, dialysis parameters, routine biochemistry and hematology, recovery time postdialysis, and Beck Depression Inventory-II score (BDI-II). Patients were followed for a minimum of 12 months. Pre- and postdialysis BP, serum calcium and phosphate were higher in the incremental center, whilst sessional Kt/Vurea was lower (all P < 0.001), as was the proportion of patients with a mean postdialysis BP <100 mmHg (P = 0.011). Patients recovered from their HD session more quickly in the incremental center, with significantly more patients reporting recovery within 1 and 4 hours Short-term survival was significantly better in the incremental center both unadjusted and adjusted for age, gender, ethnicity, dialysis vintage, anuria, history of cancer, heart disease, diabetes mellitus, body mass index, serum albumin, BDI-II score, and sessional Kt/V. The association between incremental dialysis, shorter postdialysis recovery times and improved short-term survival may be related to reduced haemodynamic stress as a consequence of less intensive ultrafiltration and reduced length of dialysis sessions. Prospective studies are required to test this hypothesis.

The effects of nebivolol and irbesartan on postdialysis and ambulatory blood pressure in patients with intradialytic hypertension: a randomized cross-over study.

Intradialytic hypertension is estimated at 5-15% of hemodialysis patients and is associated with poor prognosis. Studies on therapeutic interventions for this entity are extremely few. We aimed to evaluate the effects of nebivolol and irbesartan on peridialytic, intradialytic, and ambulatory BP in patients with intradialytic hypertension. This is a pilot randomized-cross-over study in 38 hemodialysis patients (age: 60.4 ± 11.1 years, men: 65.8%) with intradialytic hypertension (intradialytic SBP rise ≥10 mmHg at ≥4 over six consecutive sessions]. After baseline evaluation, patients were randomly assigned to nebivolol 5 mg and subsequently irbesartan 150 mg, or vice versa. Nineteen patients received a single drug-dose 1 h before hemodialysis and 19 received the drug for a week before evaluation. A 2-week wash-out period took place before the initiation of the second drug. Patients had three respective 24-h ambulatory BP measurements starting before a midweek session. In total, 20 (52.6%) patients received nebivolol first and 18 (47.4%) received irbesartan. Patients receiving a single dose of either drug had lower postdialysis BP (baseline: 160.2 ± 17.8/93.2 ± 13.6 mmHg; nebivolol: 148.0 ± 20.8/84.5 ± 13.1 mmHg, P = 0.013/P = 0.027; irbesartan 142.9 ± 29.9/87.2 ± 18.1 mmHg, P = 0.003/P = 0.104 for SBP and DBP, respectively). The 24-h BP presented a trend towards reduction, but was significant only for 24-h DBP in the nebivolol arm. Patients on weekly administration of either drug had lower postdialysis BP (baseline: 162.5 ± 16.8/95.4 ± 12.7 mmHg; nebivolol: 146.7 ± 16.3/91.8 ± 12.2 mmHg, P = 0.001/P = 0.235; irbesartan: 146.0 ± 23.9/85.8 ± 12.9 mmHg, P = 0.004/ P = 0.007, respectively), lower intradialytic BP and lower 24-h BP (baseline: 148.3 ± 12.6/90.2 ± 9.0 mmHg; nebivolol: 139.2 ± 10.6/85.0 ± 7.7 mmHg, P < 0.001/P = 0.001; irbesartan: 142.4 ± 16.4/85.1 ± 9.9 mmHg, P = 0.156/P = 0.030). No significant differences were observed in comparisons between the two drugs, with the exception of heart rate, being lower with nebivolol. Both nebivolol and irbesartan reduced postdialysis and 24-h BP in patients with intradialytic hypertension. Weekly administration had greater effect and nebivolol was numerically slightly more potent than irbesartan.

Increased Weight Gain During the Long Interdialytic Period Is Associated with Minor Effects on Blood Pressure Control in Clinically Stable In-Centre Haemodialysis Patients

Background/Aims: Three-day-a-week chronic haemodialysis (cHD) involves 1 long (72 h) and 2 short (48 h) inter-dialytic periods (IDPs). We aimed to determine whether BP control following the long IDP is inferior to the short IDPs. Methods: All pre- and post-dialysis BP and weight measurements over a 4-week period were retrospectively analyzed among 135 clinically stable cHD patients at 2 academic centres with comparisons between measurements recorded following short and long IDPs. Subsequently, 23 clinically stable cHD patients underwent 24-h ambulatory blood pressure monitoring (ABPM) during the final day/night cycle of the long IDP and 1 short IDP within the same week. Results: In combined and separate analyses of the 2 retrospective cohorts, pre-dialysis BP parameters were not different following long and short IDPs despite greater inter-dialytic weight gain (IDWG) during the long IDP. Subgroup analyses of the total cohort showed no evidence for inferior BP control during the long IDP among those with high %IDWG. In the ABPM study, nocturnal hypertension and loss of nocturnal dipping were frequent. Furthermore, daytime systolic blood pressure (SBP) and pulse pressure were modestly higher during the last day/night cycle of the long compared with short IDP. Conclusion: In stable cHD patients, the greater IDWG that occurred during the long IDP was not associated with overtly inferior BP control as reflected in pre-dialysis BP measurements. However, modestly higher daytime SBP was evident towards the end of the long IDP by 24 h ABPM. Thus, while fluid gain has well-documented associations with hypertension and adverse cardiovascular outcomes, the excess IDWG that occurs during the long IDP exerts relatively minor effects on BP control in patients on well-established dialysis regimens that are better identified by ambulatory monitoring.

Treatment of intradialytic hypotension with an herbal acupoint therapy in hemodialysis patients: A randomized pilot study

ObjectiveHypotension during hemodialysis (HD) is the most common complication that negatively affects the quality of life of patients. The objective of the current study was to evaluate the preliminary efficacy and safety of herbal acupoint therapy (HAT) for intradialytic hypotension (IDH). MethodsA randomized, placebo-controlled trial was performed in 32 HD patients to determine whether HAT was more effective than a sham treatment for the treatment of IDH. The outcomes were frequency of IDH episodes and number of nursing interventions during HD sessions, pre- and post-dialysis BP, subjective change in fatigue as measured by the Visual Analogue Scale (VAS), and recovery time from fatigue after dialysis at the 0th and 4th week. Data analyses were performed using per-protocol population. ResultsIn all, 27 patients (84%) completed the entire study. At the end of the intervention, the patients in the HAT group were found to have a significantly lower frequency of IDH episodes, fewer nursing interventions, a lower intervention failure rate, and earlier discontinuation of dialysis than those in the sham group (p < .05). The improvement in degree of fatigue (p = .001) was greater and recovery time from fatigue after dialysis (p = .03) was shorter in the group treated with HAT than in the sham group. HAT was safe, with 2 withdrawal cases due to local erythema caused by the patch. ConclusionsHAT appears to be safe and efficacious for improving IDH-related symptoms and intervention in HD patients. Larger studies are needed to confirm the benefit of this technique for IDH.

Intradialytic Hypertension: Prevalence and Associated Factors in Chronic Hemodialysis Patients in Senegal

Introduction: Intradialytic hypertension is defined as elevation of blood pressure to more than 10 mmHg in the post-dialysis period as compared to the pre-dialysis one. It is an important factor of morbidity and mortality in hemodialysis patients. The aim of our study is to assess the prevalence and associated factors of intradialytic hypertension. Patients and methods: This is a descriptive and analytical cross-sectional study that was conducted over a period of 3 weeks in the hemodialysis units of Aristide Le Dantec Hospital in Dakar and Regional Hospital Center in Ziguinchor. Chronic he-modialysis patients who are at least 18 years old and agreed to participate in study have been included. Patients who did not have 4 measures or those who decided to withdraw from the study were excluded. Intradialytic hypertension was restrained by an increase in systolic blood pressure immediately after the hemodialysis session > 10 mmHg compared to that recorded before session, with a repetition of this phenomenon for at least 4 hemodialysis sessions. Results: Our study included 539 hemodialysis sessions for 93 hemodialysis patients with a mean age of 48.72 ± 14.06 years and a sex ratio (M/F) of 1.21. The mean duration of dialysis was 64.22 ± 45.63 months. Hypertensive nephropathy was significantly common, noted in 38.7% (36 patients). Mean inter dialytic weight gain was 2.04 ± 1.06 kg, and the average dry weight was 62.71 ± 13.69 kg. The average hemoglobin level was 9.27 ± 1.91 g/dl. The mean albumin level was 35.4 ± 7.48 g/l. Nineteen (19) patients were administered erythropoietin stimulating agents (20.4%), and 59 patients were given antihypertensive drugs (63.4%). An elevation of more than 10 mmHg of post-dialysis BP compared to pre-dialysis was noted in 179 sessions, which is 33.2 per 100 hemodialysis sessions. IDH was noted in 21 patients, which represents 22.6%. The factors associated with IDH were as follows: high post-dialysis pulse pressure (PP) (p = 0.0008), pre-dialysis systolic-diastolic hypertension (p = 0.004), pre-dialysis pure systolic hypertension (p = 0.01), post-dialysis hypertension (p = 0.02), and hypoalbuminemia (p = 0.049). Conclusion: Although recognized for many years, the intradialytic hypertension is often neglected. However, it is common in our cohort of chronic hemodialysis with several associated factors. Its management is essential and will necessarily pass through adequate management of the blood volume.

Moderator's view: Ambulatory blood pressure monitoring and home blood pressure for the prognosis, diagnosis and treatment of hypertension in dialysis patients.

Major health agencies now recommend the systematic application of ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension. Given the exceedingly high prevalence of nocturnal hypertension, masked and white coat hypertension and the overt inadequacy of peridialysis (pre-, intra- and post-dialysis) BP measurements, more extensive application of ABPM for the diagnosis of hypertension in dialysis patients would appear logical. In a recent survey performed in NDT Educational, organizational problems and/or cognitive resistance emerged as important factors hindering more extensive application of ABPM and home BP by nephrologists. External validation of observations made in landmark studies in a single institution about hypertension subcategorization by ABPM is urgently needed. Furthermore, apparent cognitive resistance by nephrologists may be justified by the fact that these techniques have been insufficiently tested in the dialysis population for applicability in everyday clinical practice, tolerability, organizational impact and cost-effectiveness. We should be more resolute in abandoning peridialysis measurements for diagnosing and treating hypertension in haemodialysis patients. Home BP is a formidable educational instrument for patient empowerment and self-care, and evidence exists that this technique is superior to peridialysis values to better hypertension control as defined on the basis of ABPM. We should strive to promote more extensive application of home BP monitoring to diagnose and manage hypertension in haemodialysis patients. ABPM with novel, user friendly and better tolerated techniques is to be awaited in the near future.

Role of Twenty-Four-Hour Ambulatory Blood Pressure Monitoring in Children on Dialysis

Pre- or postdialysis BP recordings are imprecise, can be biased, and have poor test-retest reliability in children on dialysis. We aimed to examine the possible differences between pre- and postdialysis BP levels and 24-hour ambulatory BP monitoring (ABPM) in diagnosis of hypertension (HTN). Twenty-four children on dialysis had 24-hour ABPM in the interdialytic period, and values were compared with average pre- and postdialysis systolic BP (SBP) and diastolic BP (DBP) recordings that week. Each patient had an echocardiogram to determine presence of left ventricular hypertrophy (LVH). By ABPM, 8% of patients had white coat HTN and 12% had masked HTN. There was no significant difference in diagnosis of systolic HTN based on ABPM daytime SBP mean or load and postdialysis SBP. However, only 15% of patients had diastolic HTN based on postdialysis measures, whereas 46% of patients had significantly elevated daytime DBP loads and 71% had high nighttime DBP loads on ABPM. Forty-eight percent of patients were SBP nondippers. Children with LVH had higher daytime and nighttime SBP loads, significantly higher daytime and nighttime DBP loads, and lesser degree of nocturnal dipping of SBP compared with those who did not. ABPM is more informative than pre- and postdialysis BPs and improves the predictability of BP as a risk factor for target organ damage. Diagnosis and treatment monitoring of HTN among pediatric dialysis patients is enhanced with addition of ABPM.

Pre- and Postdialysis Blood Pressures Are Imprecise Estimates of Interdialytic Ambulatory Blood Pressure

BP readings that are obtained in the dialysis unit are commonly used to make therapeutic decisions by clinicians and to predict morbidity and mortality by epidemiologists. Dialysis unit BP are also incorporated in the recent guidelines to target BP control. The magnitude of the difference, overestimation or underestimation, and agreement between dialysis unit BP and ambulatory BP (ABP) are unknown. Articles were selected from Medline to identify those that reported both ABP and dialysis unit BP in hemodialysis patients. Bias was calculated as the difference between dialysis unit and the corresponding ABP. Agreement limits between the BP measurement techniques were assessed by pooled SD of the difference using Bland-Altman methods. Predialysis systolic BP generally overestimated ABP by a variable amount. The heterogeneity between BP measurements did not allow for pooling of the estimates. The agreement limits between the two BP was 41.7 to -25.2 mmHg. Predialysis diastolic BP also generally overestimated the ABP with wide agreement limits (23.7 to -18.9 mmHg). In contrast, postdialysis BP underestimated average ABP with wide agreement limits for both postdialysis systolic BP (33.1 to -36.3 mmHg) and diastolic BP (19.3 to -23.9 mmHg). Dialysis unit BP measurements are imprecise estimates of ABP. Better methods are needed for the assessment of BP in hemodialysis patients for clinical decision making.

High Pulse Pressure Associated With Cardiovascular Events in Patients With Type 2 Diabetes Undergoing Hemodialysis

The aims of this study were to examine systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and pulse pressure (PP) in patients with type 2 diabetes undergoing hemodialysis (HD), and to assess the relationships between these parameters and cardiovascular (CV) events such as coronary heart disease and congestive cardiac failure. A total of 80 Afro-Caribbean type 2 diabetic patients undergoing hemodialysis in three centers in Guadeloupe, French West Indies, were included in this cross-sectional study. Pre- and postdialysis BP were recorded. Logistic regression methods and areas under the receiver operating characteristic curves were used. The mean age (+/- standard deviation) was 62.2 years (+/-10.2 years). A total of 24 subjects (30%) had one or more CV events. Sixteen (20%) had coronary disease, 15 (18.8%) cardiac failure, and seven (8.8%) had both. The medians [interquartile ranges] for predialysis PP was higher in patients with CV comorbidity than in patients without a history of CV at 84.5 mm Hg [74.5 to 92.3]v 69.5 mm Hg [61.0 to 79.5], P = .003. Areas under the ROC curves (95% confidence intervals) predialysis were significant only for SBP and PP at 0.70 (0.58 to 0.82) v 0.71 (0.59 to 0.83) without statistical differences. After adjustment for gender, age, body mass index, antihypertensive use, time on hemodialysis (>or=2 years), and hemoglobin rate, the odds ratio was significant only predialysis, and a higher odds ratio was found for PP at 2.25 (1.22 to 4.18), P = .01, than for SBP 1.97 (1.12 to 3.49), P = .02. Our results suggest that the strongest association of PP with CV morbidities should be considered in therapeutic strategies. These results show the necessity of targeting antihypertensive treatment to patients' predialysis blood pressure values.

Contribution of Volume Overload and Angiotensin II to the Increased Pulse Wave Velocity of Hemodialysis Patients

Aortic compliance is decreased in patients with end-stage renal disease. This malfunction contributes to high aortic systolic pressures and thus to the development of left ventricular hypertrophy. It was hypothesized that besides structural vascular changes, functional changes as a result of hypervolemia and increased vasoconstrictor activity, in particular angiotensin II, play a role in decreasing aortic compliance. Nineteen hemodialysis patients were studied before and 24 h after they had been dialyzed to dry weight. Applanation tonometry of peripheral arteries was used to estimate aortic pulse wave velocity (PWV), known to depend on aortic compliance, and aortic systolic pressure augmentation (augmentation index [Aix]). Predialysis aortic PWV was increased in the dialysis patients compared with matched healthy subjects (9.9 +/- 3.1 versus 7.5 +/- 1.1 m/s; P < 0.05). The AIx was also increased (35 +/- 6 versus 25 +/- 10; P < 0.05). Volume reduction with dialysis had no significant effect on PWV (9.3 +/- 1.5 m/s), but the AIx decreased (28 +/- 7; P < 0.05). A subset of 10 patients were restudied after 1 wk of angiotensin-converting enzyme inhibition (ACEi) with enalapril 5 mg once daily. ACEi decreased both predialysis as postdialysis BP but had no effect on pulse pressure and heart rate, which remained elevated compared with healthy subjects. ACEi also decreased predialysis aortic PWV, from 11.0 +/- 3.5 to 9.1 +/- 2.1 m/s (P < 0.05) but had no significant effect on AIx. During treatment with ACEi, the same volume reduction with dialysis decreased aortic PWV further to 8.0 +/- 1.4 m/s (P < 0.05), a figure not different from PWV in healthy subjects. AIx decreased to an even slightly subnormal value (12 +/- 23; P < 0.05). It was concluded that volume overload and angiotensin II both contribute to elevated PWV and AIx in dialysis patients. Volume reduction and ACEi both improve the aortic PWV and AIx. Combined volume reduction and ACEi has an enhanced effect that, in the present patients, was so large that PWV and AIx were no longer elevated. Monitoring and correcting of arterial pressure waves is feasible and may be an important tool in the treatment of patients with end-stage renal disease.

Prediction of hypertension in chronic hemodialysis patients

There are no universally accepted criteria for the diagnosis of hypertension in hemodialysis (HD) patients. We sought to determine the clinical performance of predialysis and postdialysis systolic and diastolic blood pressure values (BPs) in diagnosing hypertension or assessing its control. Seventy patients [77% African American, 46% females, mean age 59 +/- 17 (SD) years, 34% diabetics] on chronic HD underwent a single 44-hour interdialytic ambulatory blood pressure monitoring (ABPM) and concomitant recording of BP by conventional syphygmomanometer in the HD unit for two weeks. Hypertension was defined as systolic BP (SBP) > or =135 mm Hg or diastolic BP (DBP) > or =85 mm Hg on an average 44-hour ABPM. Average ABP was 144 +/- 22/81 +/- 11 mm Hg. Seventy-three percent of the patients had systolic hypertension; 40% had diastolic hypertension, and 24% were normotensive or had well-controlled BP. Area under the curve of receiver operating characteristic (ROC) curves exceeded 80% for all BPs, but the thresholds for best sensitivity and specificity were markedly different for predialysis and postdialysis BPs. A two-week averaged predialysis BP of > 150/85 mm Hg or a postdialysis BP of > 130/75 mm Hg had at least 80% sensitivity in diagnosing hypertension. Specificity of at least 80% was achieved if predialysis BP of > 160/90 mm Hg or postdialysis BP of > 140/80 mm Hg was used. There was poor agreement between HD unit BP and ABP values. HD unit BP values can be used to identify the presence or absence of hypertension, although prediction of ambulatory BPs from HD unit BP values cannot be made reliably in individual patients.

Effects of normal hematocrit on ambulatory blood pressure in epoetin-treated hemodialysis patients with cardiac disease

Hypertension is a recognized complication of partial correction of anemia with recombinant human erythropoietin (epoetin) in hemodialysis patients. We used interdialytic ambulatory blood pressure (ABP) monitoring to study the effects of partially corrected anemia versus normal hematocrit (hct) on BP in hemodialysis patients. Repeated interdialytic ABP monitoring was performed for up to one year in 28 chronic hemodialysis patients with cardiac disease who were randomized to achieve and maintain normal hct levels (42 +/- 3%, group A) or anemic hct levels (30 +/- 3%, group B) with epoetin. Routine BP measurements obtained at dialysis treatments were also evaluated. Mean hct levels were 30.7 +/- 0.7% in group A and 30.6 +/- 0.7% in group B at baseline, then 39.3 +/- 1.2% (group A) and 33.5 +/- 0.6% (group B) at four months, and 42.0 +/- 1.1% (group A) and 30.4 +/- 1.0% (group B) at 12 months. Baseline ABP and routine dialysis unit BP levels were not different between the groups. At 2, 4, 8, and 12 months of follow-up, there were no statistically significant differences in any BP parameters between groups or increases in any BP parameters in either group A or group B patients compared with baseline. At 12 months, the mean nighttime diastolic BP (DBP) in group A patients was slightly but significantly lower than the mean daytime DBP (daytime DBP 76.6 +/- 1.9 mm Hg vs. nighttime DBP 72.9 +/- 2.1 mm Hg, P < 0.05). The mean daytime and nighttime BPs were not different from each other at two, four, and eight months in group A or at any time in group B, and in both groups, most patients had little diurnal change in BP. Correction of hct to normal with epoetin in chronic hemodialysis patients with cardiac disease did not cause increased BP as assessed by interdialytic ABP monitoring or by the measurement of routine predialysis and postdialysis BP. There was little diurnal change in systolic or diastolic BP at baseline or after correction of anemia to normal levels, and although mean nighttime DBP was lower than mean daytime DBP at 12 months in group A, the maintenance of normal hct levels did not affect the abnormal diurnal BP pattern seen at moderately anemic hct levels in most patients.

How to keep the dialysis patients normotensive? What is the secret of Tassin?

ultrafitration. Altogether the BP will increase after a few days. The In Tassin we obtain a normal BP without medication patient will then need a higher ultrafiltration rate and within the fi rst few weeks of treatment in 95% of the eventually antihypertensive drugs which, in turn, patients and they remain then normotensives through- increase the hazard of hypotensive episodes. We call out all their maintenance HD time. We strongly believe this ‘the vicious circle of shorter dialysis’. Each patient that this is due to the control of sodium and water has his own refilling capacity and therefore his own overload. Our goal is to reach the ‘dry weight’, and our need for a personalized dialysis session duration results confirm that more than 90% of cases of hyperten- according to the interdialytic weight gain. Surprisingly, sion on dialysis are due to overhydration. Furthermore the mean interdialytic weight gain in our population even in our group (with less than 3% of hypertensive is less than 2 kg. The patients do not feel thirsty, the patients) higher BP correlates with higher cardiovascular relatively low average concentration of urea and mortality and lower survival. When we split this popula- 138 mmol of Na concentration in the dialysate may tion into two cohorts according to median predialysis explain this absence of thirst. mean arterial pressure (MAP), 343 pts higher and 342 pts lower than the median (97 mmHG) the cohort The secret of Tassin? We have two secrets with lower MAP has a significantly better survival, and the number of CV death is twofold lower (13 vs 28 The first is ‘Father Time’. Opposite to what was deaths for 1000 patients/year). universally reported in the 70s when dialysis time was The method to achieve this normal BP is a quest for long, with shorter schedules, in spite of new antihyper‘dry weight’. Dry weight is that body weight at the tensive medications, 50‐80% of the patients are end of dialysis at which the patient can remain normo- hypertensive. We had the opportunity to switch to long tensive without antihypertensive medication despite dialysis 110 patients treated for 6 months or more by fluid accumulation until the next dialysis. Dry weight short HD. Half of them received BP pills and the mean keeps changing with lean and fat body mass and must of their predialytic mean MAP was 116 mmHg. After be evaluated at each session. We collect and summarize 3 months all but one were o antihypertensive treaton a chart pre- and post-dialysis weight and BP data ment and the mean MAP was 99 mmHg. in order to prescribe the ultrafiltration during the The second secret is the ‘doctor dose’. It takes a lot session. Our computer chart features on screen the last of time to explain to the patients and to the nurses the 10 sessions. After each session the doctor in charge benefit of longer dialysis, to control the chart after must validate the results and mention if the weight each session, to change the weight step by step. But must be changed. We do not wait for obvious signs of this is mandatory to reach the goal of normotension. overhydration (oedema, hypertension, etc.) but focus The results of HD depend upon quality of delivered on small signs such as headache or slight increase of treatment. The dose of dialysis must be correct, Kt/V, PCR, URR, TAC, can control this dose. Unfortunately