Post-dialysis Blood Pressure Research Articles

Correlation between postdialysis blood pressure assessed at different time points and home blood pressure monitoring

Abstract Background Hemodialysis patients undergo blood pressure (BP) measurements during the predialysis, intradialytic and postdialysis (POSBP) periods at the dialysis sessions. However, there is no consensus regarding the time point when POSBP measurement should be performed. Purpose This study investigated the relationship of POSBP measurements performed at different time points with home blood pressure monitoring (HBPM). Methods This prospective study included 98 long-term dialysis patients (67% men; age=59.4 ±17.7 years; 79% using antihypertensive medications). During one week, POSBP measurements were obtained in sitting patients by trained health staff using oscillometric BP monitors lodged in the dialysis machines at all dialysis sessions in three different periods: 1) immediately after the dialysis period ended (POSBP1); 2) after returning the patient's blood (POSBP2) and 3) after hemostasis of the fistula or catheter sealing (POSBP3). In the same week, HBPM was performed using validated devices and was calculated as the mean of BP measurements obtained on six consecutive days, comprising three readings in the morning and in the evening after at least 3 min of rest, before antihypertensive medications were taken, with the patients seated. Abnormal BP was defined as HBPM≥135/85 mmHg. Based on the optimal cut-point values derived from ROC curves analysis, we built cutoffs for POSBP1 (143/79 mmHg), POSBP2 (153/78 mmHg) and POSBP3 (151/80 mmHg) corresponding to HBPM values of 135/85 mmHg. Results The values of POSBP1, POSBP2, POSBP3 and HBPM were 138±21/72±13, 143±24/73±13, 142±22/72±13 and 128±19/76±13 mmHg, respectively. Systolic HBPM showed greater correlation with systolic POSBP3 (r=0.71), followed by POSBP1 (r=0.68), POSBP2 (r=0.67), while diastolic HBPM showed greater correlation with diastolic POSBP2 and POSBP3 (both r=0.56), followed by POSBP1 (r=0.49) (all p<0.05). The POSBP3 cutoff showed the highest association (odds ratio [95% CI]= 8.06 [3.21, 20.27]), accuracy (area under the curve [95% CI]= 0.74 [0.65, 0.83]) and concordance (kappa coefficient=0.47) to identify elevated BP at HBPM in comparison with the POSBP1 and POSBP2 cutoffs (Figure). Conclusion(s) POSBP3 exhibited the strongest correlation with HBPM and had the highest accuracy to detect elevated HBPM in dialysis patients and may be a potentially preferable POSBP measurement in clinical practice.

Influence of autonomic nervous dysfunction on eating during hemodialysis sessions: An observational study.

Although some studies have indicated that eating during hemodialysis may induce hypotension and cardiovascular events, some patients still consume food during their treatment. This prospective study was conducted to determine whether the need to eat during hemodialysis treatment was related to abnormal glucose metabolism and autonomic nerve dysfunction. Seventy patients were enrolled in this study, and their demographic features and various laboratory parameters were analyzed. At each routine hemodialysis visit, predialysis, intradialysis, and postdialysis blood pressure measurements were systematically conducted. A 24-hour ambulatory electrocardiogram (ECG) was performed during the hemodialysis interval, and heart rate variability (HRV) values were calculated. Additionally, whether the patients ate during the hemodialysis treatments was recorded. Another 20 people who underwent physical examinations during the same period and were matched for sex and age were included in the control group. The HRV values of the hemodialysis patients were generally lower than those of the control group. Univariate analysis revealed significant differences in sex, age, calcium antagonist use, blood calcium levels, insulin levels, diastolic blood pressure (DBP) measurements, and HRV indices between hemodialysis patients who ate and those who did not eat during hemodialysis (P < .05), whereas there were no significant differences in diabetes status or in the hemoglobin, albumin, blood glucose and C-peptide levels (P > .05). Multivariate analysis revealed that low values for very low frequency (VLF) and postdialysis DBP were risk factors for fasting intolerance during hemodialysis treatments. Autonomic dysfunction may affect whether hemodialysis patients tolerate fasting during dialysis. VLF evaluation may provide information that can be used to develop a more reasonable intradialytic nutritional supplementation method.

#1478 Effect of low vs standard dialysate sodium on 48-h ambulatory blood pressure in patients with intradialytic hypertension: a randomized crossover study

Abstract Background and Aims Intradialytic hypertension (IDH) is associated with increased risk for cardiovascular events and mortality. Patients with IDH exhibit higher 48-h blood pressure (BP) levels than patients without this condition. Volume and sodium excess are considered a major factor contributing in the development of this phenomenon. This study evaluated the effect of low (137 mEq/L) compared to standard (140 mEq/L) dialysate sodium concentration on 48-h BP in patients with IDH. Method In this randomized, single-blind, crossover study, 29 patients with IDH underwent 4 hemodialysis sessions with low (137 mEq/L) followed by 4 sessions with standard (140 mEq/L) dialysate sodium or vice-versa. Mean 48-h BP, pre-/post-dialysis and intradialytic BP, pre-dialysis weight, interdialytic weight gain (IDWG) and lung ultrasound B-lines were assessed. Results Mean 48-h SBP/DBP were significantly lower with low compared to standard dialysate sodium concentration (137.6 ± 17.0/81.4 ± 13.7 mmHg with low vs 142.9 ± 14.5/84.0 ± 13.9 mmHg with standard dialysate sodium, p = 0.005/p = 0.007 respectively); SBP/DBP levels were also significantly lower during the 44-h and different 24-h periods. Low dialysate sodium significantly reduced post-dialysis (SBP/DBP: 150.3 ± 22.3/91.2 ± 15.1 mmHg with low vs 166.6 ± 17.3/94.5 ± 14.9 mmHg with standard dialysate sodium, p &amp;lt; 0.001/p = 0.134 respectively) and intradialytic (141.4 ± 18.0/85.0 ± 13.4 mmHg with low vs 147.5 ± 13.6/88.1 ± 12.5 mmHg with standard dialysate sodium, p = 0.034/p = 0.013, respectively) BP compared with standard dialysate sodium. Pre-dialysis weight, IDWG and pre-dialysis B-lines were also significantly decreased with low dialysate sodium. Conclusion Low dialysate sodium concentration significantly reduced 48-h ambulatory BP compared with standard dialysate sodium in patients with IDH. These findings support low dialysate sodium as a major non-pharmacologic approach for BP management in patients with IDH. Registered at ClinicalTrials.gov with study number NCT05430438.

The association of home blood pressure with all-cause mortality in hemodialysis patients: A prospective observational study.

Prior observational studies conducted in the hemodialysis population have suggested a reverse association between dialysis-unit blood pressure (BP) and mortality. The present study aimed to investigate the prognostic association of home versus dialysis-unit BP with all-cause mortality in hemodialysis patients. At baseline, 146 patients receiving maintenance hemodialysis underwent assessment of their BP with the following methods: (i) 2-week averaged routine predialysis and postdialysis BP measurements; (ii) home BP monitoring for 1 week that included duplicate morning and evening BP measurements with the use of validated devices. Over a median follow-up period of 38 months (interquartile range [IQR]: 22-54), 44 patients (31.1%) died. In Kaplan-Meier curves, predialysis and postdialysis systolic BP (SBP) was not associated with all-cause mortality, while home SBP appeared to be of prognostic significance (log rank p = 0.029). After stratifying patients into quartiles, all-cause mortality was lowest when home SBP was ranging from 128.1 to 136.8 mmHg (quartile 2). In univariate Cox regression analysis, using quartile 2 as a referent category, the risk of all-cause mortality was 3.32-fold higher in quartile 1, 1.53-fold higher in quartile 3 and 3.25-fold higher in quartile 4. The risk-association remained unchanged after adjustment for several confounding factors (adjusted hazard ratio: 4.79, 1.79, 3.63 for quartiles 1, 3, and 4 of home systolic BP, respectively). Our findings suggest that among hemodialysis patients, 1-week averaged home SBP is independently associated with all-cause mortality. In sharp contrast, SBP recorded either before or after dialysis over 2 weeks is not prognostically informative.

Dialysis parameters associated with SARS-CoV-2 infection and prognosis in end-stage kidney disease

Background The Covid-19 pandemic has affected patients with end-stage kidney disease (ESKD). Whether dialysis parameters have a prognostic value in ESKD patients with Covid-19 remains unclear. Materials and Methods We retrospectively evaluated clinical characteristics, blood pressure (BP) and dialysis parameters in ESKD patients undergoing maintenance outpatient hemodialysis, with (Covid-ESKD) and without (No-Covid-ESKD) Covid-19, at four Brazilian hemodialysis facilities. The Covid-ESKD (n = 107; 54% females; 60.8 ± 17.7 years) and No-Covid-ESKD (n = 107; 62% females; 58.4 ± 14.6 years) groups were matched by calendar time. The average BP and dialysis parameters were calculated during the pre-infection, acute infection, and post-infection periods. The main outcomes were Covid-19 hospitalization and all-cause mortality. Results Covid-ESKD patients had greater intradialytic and postdialysis systolic BP and lower predialysis weight, postdialysis weight, ultrafiltration rate, and interdialytic weight gain during acute-illness compared to 1-week-before-illness, while these changes were not observed in No-Covid-ESKD patients. After 286 days of follow-up (range, 276–591), there were 18 Covid-19-related hospitalizations and 28 deaths among Covid-ESKD patients. Multivariable logistic regression analysis showed that increases in predialysis systolic BP from 1-week-before-illness to acute-illness (OR, 95%CI = 1.06, 1.02–1.10; p = .004) and Covid-19 vaccination (OR, 95%CI = 0.16, 0.04–0.69; p = .014) were associated with hospitalization in Covid-ESKD patients. Multivariable Cox-regression analysis showed that Covid-19-related hospitalization (HR, 95%CI = 5.17, 2.07–12.96; p < .001) and age (HR, 95%CI = 1.05, 1.01–1.08; p = .008) were independent predictors of all-cause mortality in Covid-ESKD patients. Conclusion Acute Covid-19 illness is associated with variations in dialysis parameters of volume status in patients with ESKD. Furthermore, increases in predialysis BP during acute Covid-19 illness are associated with an adverse prognosis in Covid-ESKD patients.

Low dialysate sodium and 48-h ambulatory blood pressure in patients with intradialytic hypertension: a randomized crossover study.

Intradialytic-hypertension (IDH) is associated with increased risk for cardiovascular events and mortality. Patients with IDH exhibit higher 48-h blood pressure (BP) levels than patients without this condition. Volume and sodium excess are considered a major factor contributing in the development of this phenomenon. This study evaluated the effect of low (137mEq/L) compared to standard (140mEq/L) dialysate sodium concentration on 48-h BP in patients with IDH. In this randomized, single-blind, crossover study, 29 patients with IDH underwent 4 hemodialysis sessions with low (137mEq/L) followed by 4 sessions with standard (140mEq/L) dialysate sodium or vice-versa. Mean 48-h BP, pre-/post-dialysis and intradialytic BP, pre-dialysis weight, interdialytic weight gain (IDWG) and lung ultrasound B-lines were assessed. Mean 48-h SBP/DBP were significantly lower with low compared to standard dialysate sodium concentration (137.6±17.0/81.4±13.7mmHg with low vs 142.9±14.5/84.0±13.9mmHg with standard dialysate sodium, p=0.005/p=0.007 respectively); SBP/DBP levels were also significantly lower during the 44-h and different 24-h periods. Low dialysate sodium significantly reduced post-dialysis (SBP/DBP: 150.3±22.3/91.2±15.1mmHg with low vs 166.6±17.3/94.5±14.9mmHg with standard dialysate sodium, p<0.001/p=0.134 respectively) and intradialytic (141.4±18.0/85.0±13.4mmHg with low vs 147.5±13.6/88.1±12.5mmHg with standard dialysate sodium, p=0.034/p=0.013, respectively) BP compared with standard dialysate sodium. Pre-dialysis weight, IDWG and pre-dialysis B-lines were also significantly decreased with low dialysate sodium. Low dialysate sodium concentration significantly reduced 48-h ambulatory BP compared with standard dialysate sodium in patients with IDH. These findings support low dialysate sodium as a major non-pharmacologic approach for BP management in patients with IDH.Registered at ClinicalTrials.gov with study number NCT05430438.

Associations between N-Terminal Pro-B-Type Natriuretic Peptide, Body Fluid Imbalance and Quality of Life in Patients Undergoing Hemodialysis: A Cross-Sectional Study

Natriuretic peptides may be associated with the complex interaction between malnutrition and fluid overload. This study assessed the relationship between N-terminal pro-B-type natriuretic peptide (NT-proBNP), body fluid composition, and quality of life (QOL) domains. A multicenter, cross-sectional study was conducted between 2019 and 2022. The QOL survey of 322 patients undergoing maintenance hemodialysis (227 men and 95 women; mean age, 65 ± 12 years) was conducted using the Kidney Disease QOL-Short Form v. 1.3. The patients in the higher NT-proBNP quartile group were older and had a longer dialysis vintage; lower body mass index, serum albumin, blood urea nitrogen, creatinine, sodium, uric acid, total cholesterol, triglycerides, and hemoglobin levels; lower geriatric nutritional risk index (GNRI), skeretal mascle mass index, and phase angle (PhA); and higher pre- and post-dialysis systolic blood pressure (BP), cardiothoracic index, and C-reactive protein (CRP) (p &lt; 0.05). Multivariate analysis revealed that post-dialysis systolic BP, CRP, and GNRI or PhA were independently associated with NT-proBNP. The higher NT-proBNP group experienced muscle attenuation and/or inflammation and an enlarged left atrium. Consequently, the elevated NT-proBNP by such an imbalance in body fluid composition is associated with lower health-related QOL.

Machine learning models to predict post-dialysis blood pressure in children and young adults on maintenance hemodialysis

Hypertension is associated with significant cardiovascular morbidity. Blood pressure (BP) control on maintenance hemodialysis (HD) is strongly impacted by volume status. The objective of this study was to assess whether machine learning (ML) is effective in predicting post-HD BP in children and young adults on HD. We collected data on BP, IDWG, pulse, and weights for patients on maintenance HD (> 3 months). Input features included DW, pre-post weight difference, IDWG and pre-HD BP. Seven models were trained and tuned using open-source libraries. Model performance was evaluated using time-series cross-validation on a rolling basis (3–12 month training, 1-day testing). Various regression scores were compared between models. Data for 35 patients (14,375 HD sessions) were analyzed. Extreme gradient boosting (XGB) and vector autoregression with exogenous regressors (VARX) achieved better accuracy in predicting post-dialysis systolic BP than K-nearest neighbor, support vector regression (SVR) with radial basis function kernel and random forest (p < 0.001 for each). The differences in accuracy between XGB, VARX, SVR with linear kernel, random forest and linear regression were not significant. Using clinical parameters, ML models may be useful in predicting post-HD BP, which may help guide DW adjustment and optimizing BP control for maintenance HD patients.

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.

#5660 ULTRAFILTRATION RATES IN INCIDENT PATIENTS ON INCREMENTAL HAEMODIALYSIS WITH 1 SESSION PER WEEK: ARE THESE RATES DANGEROUS?

Abstract Background and Aims Most patients start haemodialysis (HD) with a fixed dose of three sessions per week, regardless of their residual renal function (RKF). This schedule is considered “standard HD or conventional HD” and is widely accepted without any randomised controlled trial (RCT) having examined whether other schedules with fewer sessions per week are inadequate or harmful. Incremental HD (iHD), by contrast, adjusts the number of sessions to the RKF, increasing the frequency to compensate for the drop in RKF. While iHD approaches precision medicine by customising the number of sessions, it raises concerns about the risk of under-dialysis and long intersession periods. In the absence of RKF, these long periods are associated with high weight gain intersession (WGI), which leads to high ultrafiltration rates (UF rates). UF rates greater than 10 ml/kg/h are known to be associated with poor prognosis [1]. Pending ongoing RCT [2], our aim is to quantify WGI and UF rates in incident patients on iHD with a single weekly session (1HD/Wk). Method The policy of our Centre is to start with iHD in those patients with RKF and clinically stable. We start with 1HD/Wk if residual urea clearance (KrU) &amp;gt; 4 ml/min/1.73 m2. We moved from 1 to 2, and from 2 to 3 sessions/week, depending on KrU and ultrafiltration rates. We analysed 2777 HD sessions of 66 incident iHD patients, with intersession period ≥ 6 days. Mean age was 73±12.5 years and 73% were male. WGI, rate UF and Blood Pressure (BP) pre- and post-HD were analysed for each session. We calculated the monthly dialysis dose using Soluter Solver (www.ureakinetic.org). We considered an adequate dose if weekly stdKt/v ≥ 2.1 or if EKRU+KrU ≥ 12 [3]. We guided fluid management by bioimpedance spectroscopy (BIS) bimonthly. Results WGI was 1.47±1.3 kg (median 1.4), equivalent to 2±1.5% of patient weight. According to BIS, pre-HD overhydration status was 1.9±1.6 (median 1.6L), similar to WGI. The UF rate, for each session, was 5.03±3.84 ml/kg/h (median 5). 9.1% of the sessions exceeded 10 ml/min/h and 2.6% exceeded 13 ml/kg/h. Pre-dialysis BP was 158±23/78±19 mmHg (median 157/76) and post-dialysis BP was 152±27/76±16 mmHg (median 150/75). RKF measured by urinary volume was 1931±491 ml (median 1900) and KrU was 5,1±1.8 ml/mn/1.73m2 (median 4,8). Dialysis dose was adequate, with a weekly stdK/v of 2,31±0.7 volumes (median 2,23) and EKR+KrU was 14,22±3,7 ml/min (median 13,8). Nutritional status as measured by PCRn was 1,04±0.3 g/kg/day (median 1), LTI index at BIS was 12,1±4,8 kg/m2 (median 12), desirable &amp;gt;10,5, and FTI index was 15±8 kg/m2 (median 14), desirable &amp;gt;7. Conclusion Patients on iHD do not present large weight gains, nor are they subjected to high UF rates, avoiding significant changes in their BP during HD sessions. On the contrary, RKF allows them to maintain a low number of weekly sessions without presenting volume overload, underdialysis or malnutrition.

#3505 DIAGNOSING HYPERTENSION IN HEMODIALYSIS PATIENTS USING HOME VERSUS ROUTINE PERIDIALYTIC BP MEASUREMENTS

Abstract Background and Aims Although routine blood pressure (BP) measurements taken shortly before or after dialysis provide imprecise reflection of interdialytic ambulatory BP, this method continues to form the basis for the diagnosis of hypertension among patients on hemodialysis. Home BP monitoring (HBPM) is a guideline-recommended technique that may improve the diagnosis of hypertension in this population. Using 44-hour ambulatory BP monitoring (ABPM) as the reference-standard method, this study aimed to compare the diagnostic performance of home versus routine pre- and postdialysis BP recordings in hemodialysis patients. Method In 70 stable patients with end-stage kidney disease receiving thrice-weekly hemodialysis, BP was assessed with the following methods: (i) routine predialysis and postdialysis BP measurements averaged over 2 weeks; (ii) HBPM for 7 days (dublicate morning and evening measurements, Microlife WatchBP Home N); (iii) ABPM (20 min intervals over an entire interdialytic interval - 44 hours, Microlife WatchBPO3). Results The mean age of the patients was 65.3±13.3 years; 45 patients (64%) were males, and 62 (88.7%) had a known history of hypertension. The mean [95% confidence interval (CI)] of the difference between ambulatory systolic BP (SBP) and (i) predialysis SBP was 11.43 (8.24, 14.62) mmHg, (ii) postdialysis SBP was 3.9 (0.37, 7.56) mmHg, and (iii) home SBP was 8.61 (6.05, 11.17). The area under the receiver operating characteristic curve for the detection of an ambulatory daytime SBP ≥135 mmHg was significantly higher for home SBP measurements 0.934 (95% CI: 0.871-0.996) as compared to predialysis 0.778 (95% CI: 0.643-0.913) and postdialysis 0.766 (95% CI: 0.623-0.909) BP recordings (P = 0.02 for both comparisons). 1-week averaged home SBP at the cut-off point of 141.0 mmHg provided the best combination of high sensitivity (85.7%) and high specificity (92.9%) in diagnosing systolic ambulatory hypertension. Conclusion The present study shows that among patients on hemodialysis, HBPM for 1 week provides greater accuracy than 2-week averaged routine pre- and postdialysis BP recordings in the diagnosis of hypertension confirmed by the reference-standard method of interdialytic ABPM.

HOME BP MONITORING IMPROVES THE DIAGNOSIS OF HYPERTENSION IN HEMODIALYSIS PATIENTS

Objective: Although routine blood pressure (BP) measurements taken shortly before or after dialysis provide imprecise reflection of interdialytic ambulatory BP, this method continues to form the basis for the diagnosis of hypertension among patients on hemodialysis. Home BP monitoring (HBPM) is a guideline-recommended technique that may improve the diagnosis of hypertension in this population. Using 44-hour ambulatory BP monitoring (ABPM) as the reference-standard method, this study aimed to compare the diagnostic performance of home versus routine pre- and postdialysis BP recordings in hemodialysis patients. Design and method: In 70 stable patients with end-stage kidney disease receiving thrice-weekly hemodialysis, BP was assessed with the following methods: (i) routine predialysis and postdialysis BP measurements averaged over 2 weeks; (ii) HBPM for 7 days (dublicate morning and evening measurements, Microlife WatchBP Home N); (iii) ABPM (20 min intervals over an entire interdialytic interval - 44 hours, Microlife WatchBPO3). Results: The mean age of the patients was 65.3±13.3 years; 45 patients (64%) were males, and 62 (88.7%) had a known history of hypertension. The mean [95% confidence interval (CI)] of the difference between ambulatory systolic BP (SBP) and (i) predialysis SBP was 11.43 (8.24, 14.62) mmHg, (ii) postdialysis SBP was 3.9 (0.37, 7.56) mmHg, and (iii) home SBP was 8.61 (6.05, 11.17). The area under the receiver operating characteristic curve for the detection of an ambulatory daytime SBP equal or higher than 135 mmHg was significantly higher for home SBP measurements 0.934 (95% CI: 0.871-0.996) as compared to predialysis 0.778 (95% CI: 0.643-0.913) and postdialysis 0.766 (95% CI: 0.623-0.909) BP recordings (P = 0.02 for both comparisons). 1-week averaged home SBP at the cut-off point of 141.0 mmHg provided the best combination of high sensitivity (85.7%) and high specificity (92.9%) in diagnosing systolic ambulatory hypertension. Conclusions: The present study shows that among patients on hemodialysis, HBPM for 1 week provides greater accuracy than 2-week averaged routine pre- and postdialysis BP recordings in the diagnosis of hypertension confirmed by the reference-standard method of interdialytic ABPM.

USEFULNESS OF AMBULATORY BLOOD PRESSURE MEASUREMENTS IN HAEMODIALYSIS PATIENTS: A MONOCENTRIC CROSS-SECTIONAL STUDY EXTENDED TO A 5- YEAR FOLLOW-UP

Objective: Blood pressure (BP) control in haemodialysis (HD) patients is crucial given their very high cardiovascular risk. Per-dialytic BP levels do not accurately predict the cardiovascular mortality. Here, we compare the prognostic yield of 2 ambulatory BP measurement techniques in prevalent HD patients. Design and method: We recruited adult patients who had been on chronic HD for more than 3 months. Seven-day home BP monitoring (HBPM) (values of Day 1 discarded) and 44-h interdialytic ambulatory BP monitoring (iABPM) were performed. Pre- and post-dialysis BP levels were measured during the 6 dialysis sessions prior to iABPM. A 5-year follow-up was carried out to assess all-cause and cardio-vascular mortality. Results: We recruited 43 patients including 15 women. Mean age was 68.3±13 years, mean body mass index was 24.1±3.8 kg/m2, median dialysis vintage was 2.4 years [0.25;11], and 67% of patients were under anti-hypertensive medications. In patients considered as normotensive in pre-dialysis (n = 17), masked hypertension was found in 24% (11.6% of the entire cohort) and 29%, based on iABPM and HBPM, respectively. Conversely, among hypertensive patients in pre-dialysis (n = 26), “white-coat” hypertension was noted in 23% (14% of the entire cohort), either by iABPM or HBPM. In treated hypertensive patients, ambulatory techniques detected a higher proportion of uncontrolled hypertension (76% of cases in iABPM and HBPM) compared to pre-dialysis measurements (65% of cases). Focusing on the first 24 hours of iABPM underestimated the proportion of hypertensive patients (49% of the entire cohort) compared to the 44-h coverage (58% of the entire cohort). Restricting HBPM for only 3 days decreased the concordance with iABPM from 86% (k = 0.79) to 76.7% of cases (k = 0.67). After a 5-year follow-up, 25 patients were deceased including 6 patients from cardiovascular causes. All-cause mortality was associated in an adjusted model for age and gender with day-time systolic BP measured by iABPM (p = 0.045). Conclusions: In chronic HD patients, 44-h iABPM and 7-day HBPM show a reliable concordance and help to re-classify ∼25% of cases miscategorised on the basis of pre-dialysis measurements. Day-time systolic BP levels using iABPM were significantly associated with 5-year all-cause mortality.

Intradialytic Hypotension During Heamodyalysis

OBJECTIVES Haemodialysis (HD) is a form of renal replacement therapy commonly prescribed for chronic kidney disease (CKD) patients. However, it is not without deleterious haemodynamic responses which may occur either during or immediately after the termination of the procedure. These may include hypotension or hypertension. The objective of this study was to determine the frequency of intradialytic blood pressure changes in chronic kidney disease patients on maintenance hemodialysis.METHODOLOGY Patients with chronic kidney disease on maintenance hemodialysis were enrolled. Predialysis and immediate post dialysis blood pressure was recorded. Increase in postdialysis blood pressure by &gt;20mmHg was called intradialytic hypertension and decrease by &gt;20mmHg was called intradialytic hypotension.RESULTSA total of 203 patients on maintenance hemodialysis were enrolled. Age of the patients ranged from 18 to 50 years. Mean age of the patients was 39.80 ± 5.245 years. Male to female ratio was 1.8:1. Intradialytic hypotension was observed in 36 patients (17.7%) while intradialytic hypertension was observed in 22 patients (10.8%).CONCLUSIONIntradialysis blood pressure fluctuations such as hypotension and hypertension are common complications during hemodialysis. Intradialytic hypotension is more frequent.

Association between Intra- and Extra-Cellular Water Ratio Imbalance and Natriuretic Peptides in Patients Undergoing Hemodialysis

Natriuretic peptides are associated with malnutrition and volume overload. Over-hydration cannot simply be explained by excess extracellular water in patients undergoing hemodialysis. We assessed the relationship between the extracellular and intracellular water (ECW/ICW) ratio, N-terminal pro-B-type natriuretic peptide (NT-proBNP), human atrial natriuretic peptide (hANP), and echocardiographic findings. Body composition was examined by segmental multi-frequency bioelectrical impedance analysis in 368 patients undergoing maintenance dialysis (261 men and 107 women; mean age, 65 ± 12 years). Patients with higher ECW/ICW ratio quartiles tended to be older, were on dialysis longer, and had higher post-dialysis blood pressure and lower body mass index, ultrafiltration volume, serum albumin, blood urea nitrogen, and creatinine levels (p < 0.05). The ECW/ICW ratio significantly increased with decreasing ICW, but not with ECW. Patients with a higher ECW/ICW ratio and lower percent fat had significantly higher natriuretic peptide levels. After adjusting for covariates, the ECW/ICW ratio remained an independent associated factor for natriuretic peptides (β = 0.34, p < 0.001 for NT-proBNP and β = 0.40, p < 0.001 for hANP) and the left ventricular mass index (β = 0.20, p = 0.002). The ICW-ECW volume imbalance regulated by decreased cell mass may explain the reserve capacity for fluid accumulation in patients undergoing hemodialysis.

The Association Among Post-hemodialysis Blood Pressure, Nocturnal Hypertension, and Cardiovascular Risk Factors.

Most hemodialysis (HD) patients suffer from hypertension and have a heightened cardiovascular risk. While blood pressure (BP) control is essential to end-stage kidney disease (ESKD) patients, overly stringent control can lead to intradialytic hypotension (IDH). This study aimed to examine BP variations during and after HD to determine whether these variations correlate with IDH risk. BP measurements during dialysis were taken from 28 ESKD patients, and ambulatory BP monitoring was applied post-dialysis. Laboratory parameters and risk factors, including diabetes, coronary disease, and LV mass index, were compared between IDH and non-IDH groups using an independent t-test. Of the 28 patients with an average age of 57.4 years, 16 (57.1%) had diabetes, 5 (17.9%) had coronary artery disease, and 1 (3.6%) had cerebrovascular disease. The mean systolic blood pressure (SBP) during and post-HD was 142.26 mmHg and 156.05 mmHg, respectively (p=0.0003). Similarly, the mean diastolic blood pressure (DBP) also demonstrated a significant increase, from 74.59 mmHg during HD to 86.82 mmHg post-HD (p<0.0001). Patients with IDH exhibited a more substantial SBP difference (delta SBP, 36.38 vs. 15.07 mmHg, p=0.0033; age-adjusted OR=1.58, p=0.0168) and a lower post-dialysis BUN level (12.75 vs. 18.77 mg/dL, p=0.0015; age-adjusted OR=0.76, p=0.0242). No significant variations were observed in daytime and nocturnal BP between the IDH and non-IDH groups. Hemodialysis patients exhibited a marked increase in post-dialysis BP and lacked a nocturnal BP dip, suggesting augmented cardiovascular risks. This highlights the importance of more stringent BP control after hemodialysis.

Hypertension in Dialysis Patients: Diagnostic Approaches and Evaluation of Epidemiology.

Whereas hypertension is an established cardiovascular risk factor in the general population, the contribution of increased blood pressure (BP) to the huge burden of cardiovascular morbidity and mortality in patients receiving dialysis continues to be debated. In a large part, this controversy is attributable to particular difficulties in the accurate diagnosis of hypertension. The reverse epidemiology of hypertension in dialysis patients is based on evidence from large cohort studies showing that routine predialysis or postdialysis BP measurements exhibit a U-shaped or J-shaped association with cardiovascular or all-cause mortality. However, substantial evidence supports the notion that home or ambulatory BP measurements are superior to dialysis-unit BP recordings in diagnosing hypertension, in detecting evidence of target-organ damage and in prognosticating the all-cause death risk. In the first part of this article, we explore the accuracy of different methods of BP measurement in diagnosing hypertension among patients on dialysis. In the second part, we describe how the epidemiology of hypertension is modified when the assessment of BP is based on dialysis-unit versus home or ambulatory recordings.

Usefulness of American College of Cardiology/American Heart Association treatment-resistant hypertension criteria among end-stage kidney disease patients – A case series

Context: American College of Cardiology/American Heart Association (ACC/AHA) antihypertensive treatment-resistance criteria have been not used in the hemodialysis (HD) population. Aims: To assess interim Blood Pressure (BP) measures in End-Stage Kidney Disease (ESKD) patients on maintenance hemodialysis after classifying them using the ACC/AHA criteria. Methods: The study was a case series assessing blood pressure readings of ESKD patients undergoing maintenance HD at a tertiary-level care hospital in the United Arab Emirates. Blood pressure readings before, during, and after HD sessions were collected and analyzed. SPSS version 26 was used for data analysis. Results: Out of 55 patients with HD, 10 were classified as having treatment-resistant hypertension, and 6 had controlled hypertension in borderline based on mean post-dialysis Systolic BP (SBP) data of a month. Altogether, the patients underwent 183 dialysis sessions in a month with over 1000 BP readings. The treatment-resistant population showed a p-value less than 0.05 with elevated Pre-SBP, Post-SBP, Mean Intra-SBP, Mean Intra-diastolic BP (DPB), Pre-DBP, Post-DBP, Post-pulse pressure (PP), and Post-mean arterial pressure (MAP). Conclusions: Use of ACC/AHA criteria for treatment-resistant hypertension might guide setting better treatment goals among ESKD patients on maintenance HD.

PERIDIALYTIC AND INTRADIALYTIC BLOOD PRESSURE MEASUREMENTS ARE NOT VALID ESTIMATES OF 44-HOUR AMBULATORY BLOOD PRESSURE IN PATIENTS WITH INTRADIALYTIC HYPERTENSION

Objective: In contrast to pre- and post-dialysis blood pressure (BP), intradialytic and home BP measurements are accurate metrics of ambulatory BP load in hemodialysis patients. This study assessed the agreement of peridialytic, intradialytic and scheduled interdialytic recordings with 44-h interdialytic BP in a distinct hemodialysis population, patients with intradialytic-hypertension (IDH). Design and method: 45 patients with IDH (defined as: SBP rise greater than or equal to 10 mmHg from pre- to post-dialysis and post-dialysis SBP greater than or equal to 150 mmHg) with valid 48-h ABPM and 197 without IDH were included in this analysis. With 44-h BP used as reference method, we 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: In patients with IDH, peri-dialytic and intradialytic BP metrics showed at best moderate correlations, while averaged-interdialytic-SBP/DBP exhibited strong correlation (r = 0.882/r = 0.855) with 44-h SBP/DBP. Bland-Altman plots showed large between-method difference for peri- and intradialytic BP, but only + 0.7 mmHg between-method difference and good 95% limits-of-agreement for averaged-interdialytic-SBP. The sensitivity/specificity and kappa-statistic for diagnosing 44-h SBP greater than or equal to 130 mmHg were low for pre-dialysis (72.5%/40.0%, kappa-statistic = 0.074) and post-dialysis (90.0%/0.0%, kappa-statistic = -0.110), intradialytic (85.0%/40.0%, kappa-statistic = 0.198) and intradialytic plus pre/post-dialysis SBP (85.0%/20.0%, kappa-statistic = 0.043). Averaged-interdialytic-SBP showed high values of sensitivity/specificity (97.5%/80.0%,) and strong agreement (kappa-statistic = 0.775). In ROC-analyses, the peri- and intradialytic BP metrics showed bad performance with low Area-Under-the-Curve values; scheduled interdialytic SBP/DBP had the largest AUC (0.967/0.951), along with the highest sensitivity(90.0%/88.0%) and specificity(100.0%/90.0%) for detecting elevated 44-h BP. Conclusions: In patients with IDH, averaged-scheduled-interdialytic but not pre- and post-dialysis, nor intradialytic BP recordings show reasonable agreement with ambulatory BP. Interdialytic BP recordings only could be used for hypertension diagnosis and management in these subjects.

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 &lt; 140/90 mmHg and &lt; 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 &gt;140/90 mmHg was 50% (33 patients), 51,5% female. Predialysis Pulse pressure 82 mmHg Postdialysis SBP/DBP values &gt; 140/90 mmHg was 59% (39 patients), 54% female. Postdialysis Pulse pressure 83 mmHg Interdialytic BP value &gt; 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