Predialysis Blood Pressure Research Articles

Guideline-Concordant vs. Routinely Measured Predialysis Blood Pressure (BP), and Home BP in Prevalent Hemodialysis (HD) Patients

Guideline-Concordant vs. Routinely Measured Predialysis Blood Pressure (BP), and Home BP in Prevalent Hemodialysis (HD) Patients

Efficacy of a Web-Based Home Blood Pressure Monitoring Program in Improving Predialysis Blood Pressure Control Among Patients Undergoing Hemodialysis: Randomized Controlled Trial.

Hypertension is highly prevalent among patients undergoing hemodialysis, with a significant proportion experiencing poorly controlled blood pressure (BP). Digital BP management in this population has been underused. This study aimed to explore the efficacy of a web-based home BP monitoring (HBPM) program in improving predialysis BP control and enhancing knowledge, perception, and adherence to HBPM among patients with hypertension undergoing hemodialysis. A multicenter, open-label, randomized controlled trial was conducted at 2 hemodialysis units. Patients were randomly allocated in a 1:1 ratio to either the web-based HBPM program as the intervention group or to usual care as the control group over a 6-month period. The primary outcomes were the predialysis BP control rate, defined as less than 140/90 mm Hg, and the predialysis systolic and diastolic BP, assessed from baseline to the 6-month follow-up. Secondary outcomes included patient knowledge, perception, and adherence to HBPM, evaluated using the HBPM Knowledge Questionnaire, HBPM Perception Scale, and HBPM Adherence Scale, respectively. A generalized estimating equations analysis was used to analyze the primary outcomes in the intention-to-treat analysis. Of the 165 patients enrolled in the program (n=84, 50.9% in the web-based HBPM group and n=81, 49.1% in the control group), 145 (87.9%) completed the follow-up assessment. During the follow-up period, 11 instances of hypotension occurred in 9 patients in the web-based HBPM group, compared to 15 instances in 14 patients in the control group. The predialysis BP control rate increased from 30% (25/84) to 48% (40/84) in the web-based HBPM group after the 6-month intervention, whereas in the control group, it decreased from 37% (30/81) to 25% (20/81; χ22=16.82, P<.001; odds ratio 5.11, 95% CI 2.14-12.23, P<.001). The web-based HBPM group demonstrated a significant reduction after the 6-month intervention in the predialysis systolic BP (t163=2.46, P=.02; β=-6.09, 95 % CI -10.94 to -1.24, P=.01) and the predialysis diastolic BP (t163=3.20, P=.002; β=-4.93, 95% CI -7.93 to -1.93, P=.001). Scores on the HBPM Knowledge Questionnaire (t163=-9.18, P<.001), HBPM Perception Scale (t163=-10.65, P<.001), and HBPM Adherence Scale (t163=-8.04, P<.001) were significantly higher after 6 months of intervention. The implementation of a web-based HBPM program can enhance predialysis BP control and the knowledge, perception, and adherence to HBPM among patients undergoing hemodialysis. This web-based HBPM program should be promoted in appropriate clinical settings.

The prevalence and risk of mortality associated with intradialytic hypertension among patients with end-stage kidney disease on haemodialysis: A systematic review and meta-analysis.

Intradialytic hypertension (IDHTN) is a common but less frequently recognised complication of haemodialysis. However, it is associated with increased overall mortality in patients on haemodialysis. This systematic review and meta-analysis aimed to determine the prevalence of IDHTN and associated mortality risk in the global haemodialysis population. A systematic search of PubMed and EMBASE was undertaken to identify articles with relevant data published between 1990 and 2023. The pooled prevalence of IDHTN in the global haemodialysis population was determined using the DerSimonian-Laird random-effects meta-analysis. The pooled hazards ratio for mortality in patients with IDHTN was also computed from the studies that reported mortality among haemodialysis patients with IDHTN. The study protocol was registered with PROSPERO (CRD42023388278). Thirty-two articles from 17 countries were included, with a pooled population of 127,080 hemodialysis patients (median age 55.1 years, 38.2% females). Most studies had medium methodological quality (53.1%, n = 17). The overall pooled prevalence of IDHTN was 26.6% [(95% CI 20.2-33.4%), n = 27 studies, I2 = 99.3%, p<0.001 for heterogeneity], with significant differences depending on the definition used. The pooled proportion of haemodialysis sessions with IDHTN was 19.9% [(95% 12.5-28.6%, n = 8 studies, I2 = 99.3%, p<0.001 for heterogeneity)] with significant differences across the different definition criteria. The p-value for the Begg test was 0.85. The median pre-dialysis blood pressure was not significantly associated with IDHTN. The pooled hazard ratio for mortality was 1.37 (95% CI 1.09-1.65), n = 5 studies, I2 = 13.7%, and p-value for heterogeneity = 0.33. The prevalence of IDHTN is high and varies widely according to the definition used. A consensus definition of IDHTN is needed to promote uniformity in research and management. The increased mortality risk forecasted by IDHTN highlights the need for optimal blood pressure control in patients on hemodialysis.

Treatment with Sacubitril/Valsartan Effectively Manages Hypertension and Ameliorates Left Ventricular Hypertrophy in Hemodialysis Patients

Introduction: The aim of this study was to investigate the role of sacubitril/valsartan in managing hypertension and cardiac remodeling in patients undergoing hemodialysis. Methods: Hemodialysis patients with stable blood pressure control were enrolled in the study. Sacubitril/valsartan was prescribed to replace previously used angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or other antihypertensive drugs. During a 6-month follow-up period, pre-dialysis blood pressure, routine biochemical markers, and N-terminal pro-brain natriuretic peptide levels were measured. Volume status was assessed using bioelectrical impedance analysis. Endothelial damage was evaluated by measuring asymmetric dimethylarginine expression, while echocardiography and life quality assessed by Short Form-12 Health Survey were conducted at baseline and after treatment. Results: The median daily dose of sacubitril/valsartan in 32 participants was 200 mg, and no obvious adverse reactions were reported. The defined daily dose of other antihypertensive drugs (baseline 2.00 ± 1.18, end point 1.46 ± 1.30, t = 3.216, p = 0.003) reduced significantly. After treatment with sacubitril/valsartan, left ventricular ejection fraction significantly increased from 64.81 ± 8.16% to 67.55 ± 5.85% (t = −4.022, p ≤ 0.001) and the thickness of posterior wall of the left ventricle reduced from 1.05 ± 0.14 cm to 1.00 ± 0.11 cm (t = 2.063, p = 0.048). The interventricular septal thickness (baseline 1.08 ± 0.16 cm, endpoint 1.02 ± 0.12 cm, t = 2.260, p = 0.031) remarkably reduced by the end of follow-up. The tricuspid regurgitation pressure gradient decreased from 28.47 ± 8.26 mm Hg at baseline to 23.79 ± 6.61 mm Hg (t = 2.531, p = 0.020) after treatment. Conclusion: Sacubitril/valsartan effectively manages hypertension in hemodialysis patients and may also independently improve left ventricular hypertrophy and systolic function, regardless of changes in the blood pressure or the volume load.

#1058 Causal discovery for the volume of white matter in patients undergoing haemodialysis

Abstract Background and Aims White matter hyperintensity is linked to adverse outcomes and a heightened risk of overt stroke and cognitive impairment, with its prevalence being more pronounced in patients undergoing haemodialysis than in the general population. Despite this, the determinants of white matter hyperintensity volume in patients undergoing haemodialysis remain unknown. Here, we aimed to utilise a statistical causal search approach to examine the factors influencing white matter hyperintensity volume, as measured by MRI, in patients undergoing haemodialysis. Method MRI measurements of white matter hyperintensity volumes were taken in 133 patients on outpatient maintenance haemodialysis for &amp;gt;1 year. Factors included in the statistical causal discovery model encompassed sex, underlying diseases that led to dialysis, total brain volume measured using MRI, and age and dialysis vintage at the time of MRI. Additionally, values calculated and averaged over the year before the MRI scan, such as pre-dialysis blood pressure, pulse, weight, blood pressure during dialysis, blood pressure after dialysis completion, the volume of water removed in one session, Kt/V, and URR and occurrences of sudden drops in blood pressure during dialysis, were considered. Missing measurements were supplemented using random forest. A statistical causal search using DirectLiNGAM was conducted, and clear temporal pre- and post-relationships were incorporated into the LiNGAM model as per prior knowledge. To enhance internal validity, 1000 bootstrap samplings were performed, and edges with a frequency of occurrence of ≥50% were considered valid for Directed Acyclic Graphs (DAGs). Factors directly linked to white matter volume were included in the model, and linear regression was executed. Results Patients had a mean age of 69.0 (Standard Deviation: 10.4) years, with 96 (72.2%) being male. The mean history of dialysis was 6.63 [Interquartile Range (IQR): 4.10, 10.78] years, and 40 (39.2%) patients had diabetes as the primary disease. The mean white matter hyperintensity volume was 14334.9 [IQR: 5262.4,30637.2]. Age, pre-dialysis body weight, post-dialysis mean blood pressure, and total brain volume were directly influenced by white matter volume. DAGs displaying causality obtained through bootstrapping are shown in the Fig. The regression model results revealed that white matter hyperintensity increased by 8376.3 [95% Confidence Intervals (CI): 4899.5 to 11853.1] for every 10 years of age, decreased by −2726.0 [95% CI: −4311.5 to −1140.5] with a 5 kg increase in pre-dialysis body weight, increased by 2089.7 [95% CI: 693.3 to 3540.0] with a 5-mmHg rise in post-dialysis mean blood pressure, and a 1 standard deviation increase in total cerebrum volume increased white matter volume by 13057.4 [95% CI: 8958.1 to 17156.8]. Conclusion The causal diagram indicated that age, pre-dialysis weight, post-dialysis mean blood pressure, and total cerebrum volume directly influenced white matter hyper intensity volume. The sudden drop in blood pressure during dialysis impacted white matter hyperintensity volume via post-dialysis mean blood pressure. Furthermore, age, post-dialysis mean blood pressure and total cerebrum volume had a facilitative effect on the increase in white matter hyperintensity volume, while pre-dialysis weight had a protective effect.

#50 The relationship between pre-dialysis plasma endothelin-1 and the intradialytic decline in blood pressure

Abstract Background and Aims Endothelin-1 (ET-1), a potent vasoconstrictor, may play an important role in the blood pressure (BP) response to hemodialysis (HD). Patients receiving maintenance HD have higher concentrations of plasma endothelin-1 than non-HD patients with advanced chronic kidney disease or patients receiving peritoneal dialysis. We wished to examine the association between the pre-HD level of ET-1 and the magnitude of intradialytic systolic BP decline. Methods Data was collected in a prospective study of 50 patients receiving maintenance HD admitted to Brigham and Women's Hospital in Boston, MA, USA. BP was measured before and every 15 min during a single HD session using an automated BP cuff. The systolic BP decline was calculated as the pre-HD minus the lowest intradialytic systolic BP. Blood samples were collected pre-HD. Patients with missing data, HD &amp;lt;3 h, or pre-dialysis BP &amp;lt;85/55 mmHg were excluded from the analysis (n = 8). Spearman's rho (ρ) was used to assess the correlation between pre-HD ET-1 and intradialytic systolic BP decline. Results Of the 42 included patients, 17 were females, median age 62 [25th, 75th percentile: 50, 70] years. The median HD duration was 232 [210, 242] min and median ultrafiltration was 2.1 [2, 3] L. Before HD, the median ET-1 was 2.4 [1.9, 3.0] pg/mL, the median systolic BP was 141 [119, 167] mmHg, and the median diastolic BP was 68 [63, 84] mmHg. A moderate negative correlation was observed between the baseline ET-1 and the intradialytic decline in systolic BP (ρ = –0.34, P = 0.03). This correlation was stronger in patients with baseline systolic BP &amp;gt;120 mmHg (ρ = –0.51, P = 0.004, n = 30) and much stronger in patients with baseline systolic BP &amp;gt;140 mmHg (ρ = –0.66, P = 0.001, n = 21). Almost all cases (8 out of 9) with an intradialytic decline in systolic BP of &amp;gt;50 mmHg occurred in patients with baseline ET-1 below the pre-HD median level. Conclusions Our results suggest that hospitalized patients with pre-HD systolic BP &amp;gt;140 mmHg and lower baseline ET-1 may be more likely to experience larger intradialytic declines in systolic BP. Whether measurement of pre-HD ET-1 could help identify hypotensive-prone patients requires further investigation in larger studies.

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.

Prospective Study of Modifiable Risk Factors of Arterial Hypertension and Left Ventricular Hypertrophy in Pediatric Patients on Hemodialysis

IntroductionFluid and salt overload in dialysis patients result in high blood pressure (BP), left ventricular hypertrophy (LVH) and hemodynamic instability, resulting in cardiovascular morbidity and mortality. MethodsAnalysis of 910 pediatric patients on maintenance hemodialysis/hemodiafiltration (HD/HDF), prospectively followed with 2758 observations recorded every 6-months in the International Pediatric Hemodialysis Network. ResultsUncontrolled hypertension was present in 55% of observations, with 27% of patients exhibiting persistently elevated pre-dialysis BP. Systolic and diastolic, height- and age-standardized BP (BP-SDS) were independently associated with number of antihypertensive medications (OR=1.47 [1.39-1.56], 1.36 [1.23-1.36]) and interdialytic weight gain (IDWG; 1.19 [1.14-1.22], 1.09 [1.06-1.11]). IDWG was related to urine output (OR=0.27 [0.23-0.32]) and dialysate sodium (dNa; 1.06 [1.01-1.10]; all p<0.0001). In subjects with pre-dialysis and 24h-BP measurements, the prevalence of masked hypertension was 24%, and HD versus HDF use was an independent risk factor of elevated MAP-SDS (OR=2.28 [1.18-4.41], p=0.01).51% of 1135 echocardiograms demonstrated LVH. Modifiable risk factors included pre-dialysis systolic BP-SDS (OR=1.06 [1.04-1.09], p<0.0001), blood hemoglobin (0.97 [0.95-0.99], HD versus HDF modality (1.09 [1.02-1.18], p=0.01) and IDWG (1.02 [1.02-1.03], p=0.04). Additionally HD modality increased the risk of LVH progression (OR=1.23 [1.03-1.48]). Intradialytic hypotension (IDH) was prevalent in patients progressing to LVH and independently associated with pre-dialysis BP-SDS below 25th percentile, lower number of antihypertensives, HD versus HDF modality, ultrafiltration rate and urine output, but not with dNa. ConclusionsUncontrolled hypertension and LVH are common in pediatric hemodialysis, despite intense pharmacological therapy. Outcome may improve with use of HDF, and superior anemia and IDWG control; the latter via lowering dNa, without increasing the risk of IDH.

IL-6 and IL-17 as potential links between pre-existing hypertension and long-term COVID sequelae in patients undergoing hemodialysis: a multicenter cross-sectional study

Long COVID, characterized by persistent symptoms following acute infection, poses a significant health challenge, particularly for patients with pre-existing chronic conditions such as hypertension. We hypothesized that an increase in the production of interleukins (IL)-6 and IL-17 could serve as a potential mechanism linking pre-existing uncontrolled blood pressure (BP) to the occurrence of long-term COVID sequelae in patients undergoing hemodialysis (HD). This cross-sectional study examined serum IL-6 and IL-17 levels in 80 patients undergoing HD, considering preinfection BP, the presence of long-term COVID sequelae, and the time interval after acute COVID-19 infection, which was either 5 or 10 months. Controlled BP was defined as a 3-month average pre-dialysis BP < 140/90 mmHg and post-dialysis < 130/80 mmHg. The findings suggest that the prevalence of long-term COVID sequelae was significantly higher in patients with uncontrolled BP than in the BP-controlled group. Both IL-6 and IL-17 concentrations were also significantly higher in patients with uncontrolled BP compared with the BP-controlled group. The patients with long-term COVID sequelae had higher IL-6 and IL-17 values than the fully recovered patients at both time points, but their concentrations decreased significantly over time. Further research and prospective studies are warranted to validate these findings.

Dialysate Sodium Lowering in Maintenance Hemodialysis: A Randomized Clinical Trial.

Lowering dialysate sodium may improve volume and blood pressure control in maintenance hemodialysis patients. We randomized 42 participants 2:1 to dialysate sodium 135 vs. 138 mEq/L for 6 months. This was followed by a 12 week extension in which sodium was increased to 140 mEq/L in low arm participants. The primary outcome was intradialytic hypotension (IDH). Secondary outcomes included dialysis disequilibrium symptoms, ER visits/hospitalizations, interdialytic weight gain, blood pressure (BP). Longitudinal changes across arms were analyzed using linear mixed regression. Treatment to dialysate sodium 135 vs. 138 mEq/L was not associated with a difference in a change in the rate of IDH (mean change (95%CI) 2.8 (0.8,9.5) vs. 2.7 (1.1, 6.2) events per 100 treatments per month; ratio of slopes 0.96(0.26,3.61) or ER visits/hospitalizations (7.3 (2.3, 12.4) vs. 6.7 (2.9, 10.6) events per 100 patient months; difference 0.6(-6.9,5.8). Symptom score was unchanged in the 135 mEq/L arm (0.7 (-1.4,2.7) and decreased in the 138 mEq/l arm (5.0,8.5,2.0); difference 6.0 (2.1,9.8)). Interdialytic weight gain declined in the 135 mEq/L arm and was unchanged in the 138 mEq/L arm,(-0.3(-0.5,0.0) vs. 0.3 (0.0, 0.6) kg over 6 months; difference (-0.6 (-0.1,-1.0) kg). In the extension phase, raising dialysate sodium from 135 to 140 mEq/L was associated with an increase in interdialytic weight gain (0.2 (0.1, 0.3) kg), predialysis BP (7.0 (4.8, 9.2)/ 3.9 (2.6, 5.1) mm Hg) and a reduction in IDH [OR 0.66 (0.45, 0.97)]. Use of a dialysate sodium of 135 as compared with 138 mEq/L was associated with a small reduction in interdialytic weight gain without impact on IDH or predialysis BP, but with an increase in symptoms. Raising dialysate sodium from 135 to 140mEq/L was associated with a reduction in IDH, a small increase in interdialytic weight gain and a marked increase in predialysis BP.

Ambient temperature and the occurrence of intradialytic hypotension in patients receiving hemodialysis.

Intradialytic hypotension (IDH) is a common hemodialysis complication causing adverse outcomes. Despite the well-documented associations of ambient temperatures with fluid removal and pre-dialysis blood pressure (BP), the relationship between ambient temperature and IDH has not been adequately studied. We conducted a cohort study at a tertiary hospital in southern Taiwan between 1 January 2016 and 31 October 2021. The 24-h pre-hemodialysis mean ambient temperature was determined using hourly readings from the weather station closest to each patient's residence. IDH was defined using Fall40 [systolic BP (SBP) drop of ≥40mmHg] or Nadir90/100 (SBP <100 if pre-dialysis SBP was ≥160, or SBP <90mmHg). Multivariate logistic regression with generalizing estimating equations and mediation analysis were utilized. The study examined 110400 hemodialysis sessions from 182 patients, finding an IDH prevalence of 11.8% and 10.4% as per the Fall40 and Nadir90/100 criteria, respectively. It revealed a reverse J-shaped relationship between ambient temperature and IDH, with a turning point around 27°C. For temperatures under 27°C, a 4°C drop significantly increased the odds ratio of IDH to 1.292 [95% confidence interval (CI) 1.228 to 1.358] and 1.207 (95% CI 1.149 to 1.268) under the Fall40 and Nadir90/100 definitions, respectively. Lower ambient temperatures correlated with higher ultrafiltration, accounting for about 23% of the increased IDH risk. Stratified seasonal analysis indicated that this relationship was consistent in spring, autumn and winter. Lower ambient temperature is significantly associated with an increased risk of IDH below the threshold of 27°C, irrespective of the IDH definition. This study provides further insight into environmental risk factors for IDH in patients undergoing hemodialysis.

Real-world trends in pre-dialysis blood pressure levels of patients undergoing dialysis in Japan using a web-based national database.

The prevalence of hypertension is high among patients undergoing dialysis. We extracted data of patients undergoing dialysis between 2012 and 2020 with recorded pre-dialysis systolic blood pressure (SBP) using a web-based national database in Japan. Following the 2019 Japanese Society of Hypertension guidelines, we classified SBP and assessed its trends over time based on sex, age, diabetes status, and the anti-hypertensive medication use. Using the 2020 database, we examined 336,759 Japanese patients undergoing dialysis (114,249 female; 222,510 male). The mean age was 69.4±12.5years, and the mean SBP was 152.3±24.7mm Hg. The prevalence rate of pre-dialysis hypertension was 70.2%, with 32.5%, 24.5%, and 13.2% of patients having grade I, grade II, and grade III hypertension, respectively. From 2014 to 2020, prevalence rate of pre-dialysis hypertension and absolute values of pre-dialysis SBP were higher in dialysis patients with diabetes than in those without diabetes across all age groups and sexes. Younger patients with diabetes or those on anti-hypertensive medication exhibited an SBP of approximately 160mm Hg. Cerebrovascular death in patients with diabetes was associated with a higher rate of pre-dialysis hypertension than that in those without diabetes, and there was a significant difference in the prevalence of grade III hypertension between the two groups. In conclusion, the mean pre-dialysis SBP among patients undergoing dialysis remained high, and younger patients with diabetes or those receiving anti-hypertensive medications had poor blood pressure control. Optimal blood pressure management may be necessary to reduce the risk of cardiovascular mortality.

Regional variation in pre-dialysis blood pressure and its association with cardiovascular mortality rates in Japanese patients undergoing dialysis.

Adequate blood pressure (BP) management poses a significant challenge in improving the prognosis of patients undergoing dialysis. We aimed to investigate the relationship between pre-dialysis systolic blood pressure (SBP) and underlying disease in Japanese patients undergoing dialysis, based on prefectural location, and assess the association between pre-dialysis SBP and cardiovascular disease (CVD) mortality rate. We extracted the basic information of 336,182 patients who were undergoing dialysis in 2021 from the Web-based Analysis of Dialysis Data Archives database. Data on average pre-dialysis SBP were analyzed according to sex, prefectural location, and diabetic status, and the CVD mortality rate for each prefecture was calculated. The mean pre-dialysis SBP of the patients (males, 66.3%; mean age, 69.7 ± 12.5 years) was 151.9 ± 24.7 mmHg. Overall, 133,037 patients had underlying diabetic kidney disease (DKD). The patients with DKD were younger, had a shorter dialysis duration, and a higher pre-dialysis SBP than those with non-DKD comorbidities. The prefecture-based mean pre-dialysis SBP values were all higher than 140 mmHg. At the prefectural level, CVD mortality rate was positively correlated with pre-dialysis SBP (r = 0.3127, p = 0.0324) and diastolic blood pressure (r = 0.3378, p = 0.0202) among female patients. At the prefectural level, pre-dialysis SBP is >140 mmHg in Japanese patients undergoing dialysis, especially in those with DKD. The positive association between pre-dialysis SBP and CVD mortality rate suggests that optimal BP management at the prefectural level may reduce CVD mortality rates. At the prefectural level, pre-dialysis SBP is higher than 140 mmHg in Japanese patients undergoing dialysis, especially higher in those with DKD.

Impact of Hemodialysis Time Prolongation on Blood Pressure Control

Abstract Introduction Hypertension prevalence among ESRD patients range from 76% to 90%. Sodium &amp; volume overload is among the main mechanisms. Increasing the duration of dialysis time, either by longer session hours or increased sessions, aiming at reducing the dry weight to achieve euvolemia, may be beneficial for individuals who failed to achieve target BP or ideal volume status during standard HD prescription hours. We aim to study the effect of increasing hemodialysis session time on blood pressure control. Methods This observational study was conducted on 50 adult clinically stable hypertensive prevalent HD patients on thrice weekly maintenance HD. Patients with secondary causes of hypertension and Patients with decompensated medical conditions were excluded from our study. Patients were divided into 2 groups: (A) 25 patients who received longer session hemodialysis session (4.5 hour) and (B) 25 patients HD who received the usual 4 hours session. Revision of antihypertensive medications&amp; dosages, dry weight was reassessed regularly, and they were instructed to restrict their salt intake as much as possible aiming at BP &amp;lt; 140/90 mmHg. they were followed up for a period of 6 months assess changes of pre-dialysis blood pressure to monitor response. Results Patients in both groups were age matched, with male sex predominance (64%in groupA&amp;56% in groupB). Patients in both groups underwent their HD sessions mostly through AVF (68% and 92% for group A and B respectively). Ultrafiltration volume declined significantly with longer HD sessions compared to conventional sessions (pvalue &amp;lt;0.001 vs 0.523). Longer HD session time session was associated with highly significant decline in mean SBP, (p-value &amp;lt;0.001). Longer HD session time session was associated with highly statistically significant decline in mean DBP, (p-value &amp;lt;0.001). The decline in mean perdialysis SBP &amp; DBP was -17.27 &amp;-9 mmHg, respectively and the rate of decline of postdialysis SBP &amp; DBP was -6.45 &amp; -12.38 mmHg, respectively at 6th month compared to values in 1st month of follow up period. Conclusion Longer HD session duration is associated with better improvement in UF volume, mean SBP&amp;DBP, pre-dialysis SBP&amp;DBP and post-dialysis SBP&amp;DBP as well.

Influence of blood pressure variations during hemodialysis on the prognosis of dialysis patients

ABSTRACT The prognosis of dialysis patients is poorer than that of the general population. The relationship between dialysis patients’ blood pressure (BP) and mortality is controversial. We investigated the relationships between mortality and (i) pre-dialysis BP and (ii) BP variation during hemodialysis in maintenance dialysis patients. We retroactively analyzed the cases of the 284 patients on hemodialysis (mean age 68 ± 13 years old) who had been regularly followed at Kokura Daiichi Hospital, Japan in 2018. We assessed the relationship between the patients’ BP components and risk of mortality over a 40-month follow-up. The patients’ average systolic/diastolic BP values before dialysis in 2018 were 145 ± 18/77 ± 11, and those after dialysis were 129 ± 17/71 ± 10 mmHg. The prevalence of intradialytic hypotension was 46.8%. During an average follow-up of 35 months, 72 patients died, including from infectious diseases (n = 41), cardiovascular diseases (n = 9), malignancies (n = 5), and others (n = 17). The mortality rate was 32.7% in the pre-dialysis SBP < 140 mmHg group, 20.6% in the 140–159 mmHg group, and 22.2% in ≥ 160 mmHg group. In a multivariable-adjusted analysis, the hazard ratio for mortality in the pre-dialysis SBP < 140 mmHg group with intradialytic hypotension was significantly higher than that in the 140–159 mmHg group. In dialysis patients, pre-dialysis SBP < 140 mmHg and intradialytic hypotension posed a significantly higher risk for mortality. Our findings suggest that not only lower pre-dialysis BP, but also intradialytic hypotension is associated with poor prognosis in dialysis patients.

Impact of frequent intradialytic hypotension on quality of life in patients undergoing hemodialysis

BackgroundIntradialytic hypotension (IDH) is frequently accompanied by symptoms of nausea, dizziness, fatigue, muscle spasm, and arrhythmia, which can adversely impact the daily lives of patients who undergo hemodialysis and may lead to decreased quality of life (QoL). This study employed the KDQOL™-36 scale to evaluate the impact of frequent IDH, based on the definition determined by predialysis blood pressure (BP) and nadir systolic blood pressure (SBP) thresholds, on the QoL of patients.MethodsThis is a single center retrospective cohort study involving 160 hemodialysis patients. We enrolled adult patients with uremia who received routine hemodialysis (4 h/time, 3 times/week) from October 1, 2019, to September 30, 2021. Frequent IDH was defined as an absolute nadir SBP < 90 mmHg occurring in no less than 30% of hemodialysis sessions when predialysis SBP < 159 mmHg (or < 100 mmHg when predialysis BP ≥ 160 mmHg).The differences between patients with and without frequent IDH were compared using the independent t test, Kruskal‒Wallis test, or chi-square test. The primary visit was at month 36, and the remaining visits were exploratory outcomes.ResultsCompared to patients with infrequent IDH at baseline, those with frequent IDH had significantly lower scores on the symptoms and discomfort of kidney disease dimension at all follow-up points (P < 0.05). The symptoms and discomfort of kidney disease dimension were worse in patients with frequent IDH. Those with frequent IDH had a significantly poorer QoL regarding the dimensions of symptoms and discomfort of kidney disease and the impact of kidney disease on life.ConclusionsThe findings of the study suggest an association between frequent IDH and QoL dimensions of symptoms and discomfort of kidney disease and the impact of kidney disease on life dimension under the definition of frequent IDH.

Evaluation of hypertension control among hemodialysis patients in Pakistan: a prospective follow-up study.

Hypertension is highly prevalent and uncontrolled among hemodialysis patients. In Pakistan published data does not provide enough information about the management and factors associated with uncontrolled hypertension in hemodialysis patients. This study was conducted to evaluate the factors influencing the pharmacotherapeutic management and control of hypertension in hemodialysis patients. A prospective follow-up study was conducted on hemodialysis patients who were enrolled at study sites between 1 June 2020 and 31 December 2020. The predialysis blood pressure (BP) readings were recorded as mean SBP and DBP at baseline and for each of 6 months. Multivariate analyses were applied to analyze the factors associated with uncontrolled hypertension in hemodialysis patients. The average predialysis BP (SBP and DBP) of study participants at baseline visit was 158.41 and 87.22 mmHg respectively. After 6 months the study participants have 150.27 mmHg and 80.03 mmHg average predialysis SBP and DBP respectively. Only 28.1% of hemodialysis patients were on target BP after 6 months. Results of multivariate analysis have shown that the use of beta-blockers and calcium channel blockers (CCBs) were significantly associated with hypertension control at baseline [odds ratio (OR) = 1.432, P value = 0.034] (OR = 1.499, P value = 0.045) and at after 6 months (OR = 2.824, P value = 0.015) (OR = 1.883, P value = 0.032). This study revealed that among the antihypertensive drugs, CCBs and beta-blockers provided better management in controlling hypertension among hemodialysis patients.

α-Blocker Use in Hemodialysis: The Japan Dialysis Outcomes and Practice Patterns Study

Despite α-blockers' use for hypertension as add-on therapy in patients treated with hemodialysis, scant information is available on their association, particularly with safety, in these patients. Prospective cohort study. patients treated with hemodialysis and receiving antihypertensive agents in the Japan Dialysis Outcomes and Practice Patterns Study, phases 4-6, were analyzed. Primary exposure was the prescription of α-blocking antihypertensive agents at baseline. Incident fractures, falls, and all-cause mortality. Multivariable Cox and modified Poisson regression analysis. Of 5,149 patients treated with hemodialysis (mean age, 65 years; 68% men) receiving antihypertensive drugs, 717 (14%) received α-blocking agents. During a mean follow-up period of 2.0 years, 247 fractures, 525 falls, and 498 deaths occurred. Multivariable analysis showed no significant association of α-blocker use and increased risk of fractures (hazard ratio [HR], 0.92 [95% confidence interval {CI}, 0.61-1.38]), falls (HR, 0.94 [95% CI, 0.74-1.20]), or all-cause deaths (HR, 0.87 [95% CI, 0.64-1.20]) compared with α-blocker nonuse. α-Blocker use was, however, significantly associated with a decreased risk of all-cause mortality in the subgroup analysis, for example, patients who were older (HR, 0.71 [95% CI, 0.51-0.99]), were women (HR, 0.68 [95% CI, 0.48-0.95]), or reported a history of cardiovascular disease (HR, 0.67 [95% CI, 0.48-0.95]) or a predialysis blood pressure of≥140 mm Hg (HR, 0.69 [95% CI, 0.49-0.98]). Selection bias cannot be ruled out given the prevalent user analysis. No significant association between α-blocker use and the risk of worse safety-related outcomes was seen, indicating that clinicians may safely prescribe α-blockers to patients receiving hemodialysis who require blood pressure lowering. α-Blockers have been generally reserved for use as add-on therapy for resistant or refractory hypertension. However, little is known about the safety of α-blockers in patients treated by hemodialysis. We analyzed 5,149 patients receiving hemodialysis in Japan who were receiving antihypertensive drugs from the Japan Dialysis Outcomes and Practice Patterns Study. The results showed no significant increase in the risk of fractures, falls, or deaths for patients using α-blockers compared with those who did not, suggesting that α-blockers may be safely prescribed for patients receiving hemodialysis who need to lower their blood pressure.

Different time points, different blood pressures: complexity of blood pressure measurement in hemodialysis patients.

We used our established database to investigate predialysis blood pressure (BP) measurements at different time points. Our study period spanned from 1 January 2019 to 31 December 2019. The different time points included: the long interdialytic interval versus the short interdialytic interval; different hemodialysis shifts. Multiple linear regression was used to explore the association between BP measurements and different time points. A total of 37 081 cases of hemodialysis therapies were included. After a long interdialytic interval, predialysis SBP and DBP were significantly elevated. Predialysis BP was 147.72/86.73 mmHg on Monday and 148.26/86.52 mmHg on Tuesday, respectively. Both predialysis SBP and DBP were higher in the a.m. shift. The mean BP in the a.m. and p.m. shifts were 147.56/87 mmHg and 144.83/84.64 mmHg, respectively. In both diabetic nephropathy and non-diabetic nephropathy patients, higher SBP measurements after a long interdialytic interval were observed; however, in diabetic nephropathy patients, we did not find significant differences in DBP among different dates. In diabetic nephropathy and non-diabetic nephropathy patients, we observed that the effect of different shifts on BP was similar. In Monday, Wednesday and Friday subgroups, the long interdialytic interval was also associated with BP; however, in Tuesday, Thursday and Saturday subgroups, different shifts but not the long interdialytic interval was associated with BP. The long interdialytic interval and different hemodialysis shifts have a significant effect on predialysis BP in patients with hemodialysis. When interpreting BP in patients with hemodialysis, different time points is a confounder.