Predialysis Diastolic Blood Pressure Research Articles

Oxidative stress and other risk factors for white matter lesions in chronic hemodialysis patients

Chronic kidney disease (CKD) is a risk factor for cardiovascular disease and promotes oxidative tress (OS), which has been implicated in the pathogenesis of white matter lesions (WML), a form of small-vessel cerebrovascular disease. The relationship between OS and WML in chronic hemodialysis (HD) patients has not yet been studied. We studied 67 chronic HD patients, aged 40 - 65 years (average 54 years) without known cerebrovascular disease. All patients underwent brain magnetic resonance imaging and subcortical and periventricular WML were evaluated using semiquantitative measures. Patients were classified into two groups depending on the presence or absence of WML (Fazekas classification), and the WML were scored. Carotid ultrasonography was also performed to evaluate the presence of carotid artery plaques and/or stenosis. Markers of protein and lipid oxidation (protein carbonyl and oxLDL antibodies), the glutathione system, enzymatic antioxidants (superoxide dismutase, glutathione peroxidase, glutathione reductase and catalase) and total antioxidant capacity (ORAC) were measured. OS markers were compared to those of a group of 36 healthy subjects. WML were present in 54% of the total population. Patients who had WML were older and had lower predialysis diastolic blood pressure than patients without WML. Other potential cardiovascular risk factors for WML, including obesity, hyperlipidemia, diabetes mellitus, presence of carotid artery plaques or stenosis, and duration and adequacy of HD were not related to the presence of WML. Compared to controls, HD patients had increased OS and decreased antioxidant capacity. However, OS did not differ between patients with WML and those without, and we found no association between OS markers and mean WML scores. After adjusting for several factors, only age and low predialysis diastolic blood pressure independently predicted an increased risk of WML. Our results confirm that chronic HD patients have increased OS, but this is not related to the presence or severity of WML.

Are there any seasonal changes of cognitive impairment, depression, sleep disorders and quality of life in hemodialysis patients?

ObjectiveCognitive impairment, depression, sleep disorders and impaired quality of life are very common in hemodialysis (HD) patients. However, whether there are any seasonal changes of cognitive impairment, depression, sleep disorders and quality of life in HD patients is not known. MethodsThe laboratory parameters, depressive symptoms, health-related quality of life, sleep quality (SQ) and cognitive function, were measured twice. ResultsA total of 66 HD patients were enrolled. Pre-dialysis systolic blood pressure (BP) and pre-dialysis diastolic BP were higher, whereas predialysis creatinine and sodium were lower in January compared to July. Among domains of Short Form 36 (SF-36), physical functioning, role-physical limitation, general health perception, vitality, role emotional, Physical Component Summary Score (PCS) were higher, whereas Beck Depression Inventory (BDI) score was lower in July compared to January. Stepwise linear regression analysis revealed that only change in albumin and smoking status were related with seasonal change of BDI scores. Additionally only change in Mental Component Summary score of SF-36 were related with change in PCS score of SF-36 scores. ConclusionsDepressive symptoms and quality of life but not SQ and cognitive function showed seasonal variability in HD patients.

Blood pressure levels and mortality risk among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study

KDOQI practice guidelines recommend predialysis blood pressure <140/90 mm Hg; however, most prior studies had found elevated mortality with low, not high, systolic blood pressure. This is possibly due to unmeasured confounders affecting systolic blood pressure and mortality. To lessen this bias, we analyzed 24,525 patients by Cox regression models adjusted for patient and facility characteristics. Compared with predialysis systolic blood pressure of 130-159 mm Hg, mortality was 13% higher in facilities with 20% more patients at systolic blood pressure of 110-129 mm Hg and 16% higher in facilities with 20% more patients at systolic blood pressure of ≥160 mm Hg. For patient-level systolic blood pressure, mortality was elevated at low (<130 mm Hg), not high (≥180 mm Hg), systolic blood pressure. For predialysis diastolic blood pressure, mortality was lowest at 60-99 mm Hg, a wide range implying less chance to improve outcomes. Higher mortality at systolic blood pressure of <130 mm Hg is consistent with prior studies and may be due to excessive blood pressure lowering during dialysis. The lowest risk facility systolic blood pressure of 130-159 mm Hg indicates this range may be optimal, but may have been influenced by unmeasured facility practices. While additional study is needed, our findings contrast with KDOQI blood pressure targets, and provide guidance on optimal blood pressure range in the absence of definitive clinical trial data.

The Effect of Education Given to Hemodialysis Patients on Blood Pressure and Weight Gain

ObJective: This study aimed to investigate effect of salt and fluid restriction education for patients undergoing hemodialysis and nonadherent to fluid restriction treatment on blood pressure and weight gain. mateRiaL and metHODs: The study sample consisted of 100 patients, nonadherent to fluid restriction treatment, undergoing routine 3 times a week hemodialysis treatment at a hemodialysis center. Salt and fluid restriction education was given to patients once a week during two consecutive weeks. Pre and post-hemodialysis weight and means, interdialytic weight gain and means, predialysis systolic and diastolic blood pressures and means were measured. RESultS: 67 male and 33 female patients were included. The average age was 56.2 ±13.5 years. Mean hemodialysis time was 54.7+-42.1 months. After education, there was a significant reduction in pre-dialysis weight means (p<0.001) and mean interdialytic weight gain (p:0.006). Also there was a decrease in pre-dialysis systolic blood pressure means (p:0.035) after the education. However, there was no reduction in pre-dialysis diastolic blood pressure means. coNluSioN: If patients undergoing hemodialysis are given sufficient education about salt and fluid restriction; they are eager to follow salt and fluid restriction treatment. KeY WORDs: Hemodialysis, Fluid restriction, Education Yazisma Adresi: emre eRDem Ondokuz Mayis Universitesi Tip Fakultesi, Nefroloji Bilim Dali, Samsun, Turkiye Tel : 0 362 433 11 77 E-posta : emredlk@yahoo.com Gelis Tarihi : 25.05.2011 Kabul Tarihi : 15.07.2011 doi: 10.5262/tndt.2012.1001.07 Turgut Kurt Y ve ark : Hemodiyaliz Hastalarina Verilen Egitimin Kan Basinci ve Kilo Alimina Etkisi Turk Neph Dial Transpl 2012; 21 (1): 39-44 40 turk nefroloji Diyaliz ve transplantasyon Dergisi Turkish Nephrology, Dialysis and Transplantation Journal

P Wave Dispersion Increases during Hemodialysis Sessions

Background/Aims: Atrial fibrillation (AF) is common among hemodialysis (HD) patients and is associated with high mortality. P wave dispersion (PWD) is a noninvasive electrocardiographic marker of paroxysmal AF. Our aim was to evaluate the effect of HD session on PWD. Methods: Twenty-five patients (mean age 63 years, 10 males) with sinus rhythm and undergoing chronic HD treatment were included. Blood samples were drawn and 12-lead electrocardiograms were recorded immediately before HD session, at the 2nd hour during HD and at the end of the HD session. The difference between maximum and minimum P wave durations was calculated as PWD. Results: PWD significantly increased during HD sessions compared with predialysis values (41 ± 12 vs. 21 ± 10 ms, respectively, p < 0.001), then decreased to a value of 24 ± 7 ms at the completion of HD, which was not significantly different from the predialysis values. PWD during HD was significantly correlated with predialysis systolic and diastolic blood pressure (r = 0.42, p = 0.037, and r = 0.59, p = 0.002, respectively) and predialysis serum potassium level (r = 0.44, p = 0.031). Linear regression model revealed that predialysis diastolic blood pressure (p = 0.002), predialysis serum potassium level (p = 0.037) and the amount of ultrafiltration (p = 0.048) were the significant predictors of prolonged PWD during HD. Conclusion: PWD increases significantly during HD sessions. This may increase the risk of AF episodes during HD. High diastolic blood pressure and serum potassium level before HD and ultrafiltration amount may predict prolonged PWD during HD.

Prevalence and Determinants of Hypertension in Chronic Hemodialysis Patients in Japan

Hypertension is common in chronic hemodialysis (HD) patients. However, its prevalence and determinants have not been studied in a large HD population. We analyzed the database of the Japanese Society for Dialysis Therapy (JSDT) registry, which conducts an annual survey of chronic dialysis patients throughout Japan. We compiled those who were on HD three-times per week and aged 20 years and over at the end of 2000 (JSDT standard analysis file 001). Hypertension was defined as predialysis systolic blood pressure (SBP) > or =140 mm Hg or predialysis diastolic blood pressure (DBP) > or =90 mm Hg. Adjusted odds ratios (95% confidence interval) for the determinants of hypertension were calculated by the multivariate logistic regression analysis. A total of 65 393 people (men, 60.2%; mean age +/- SD, 60.9 +/- 12.8 years; and mean duration of HD +/- SD, 95.3 +/- 74.0 months) were studied. Mean +/- SD levels of SBP and DBP were 154.9 +/- 23.8 mm Hg and 80.5 +/- 13.7 mm Hg before the HD session. Hypertension was noted in 77.5% of patients. Prescription of antihypertensive drugs and erythropoietin was made to 60.7% and 82.0% of patients, respectively. Both SBP and DBP were higher in those who were prescribed antihypertensive drugs (mean, 160.4/81.9 mm Hg), than those without drugs (mean, 146.9/78.5 mm Hg) (in both cases P < 0.0001). Hypertension was positively associated with men (adjusted odds ratio (OR), 1.258; 95% confidence interval (CI), 1.188-1.333; P < 0.0001), age (OR, 1.004; CI, 1.001-1.006; P < 0.01), duration of HD (OR, 0.769; CI, 0.728-0.812; P < 0.0001), serum albumin (OR, 1.369; CI, 1.286-1.458; P < 0.0001), and change in body weight by dialysis session (DeltaBW) (OR, 1.176; CI, 1.159-1.194; P < 0.0001), and was negatively associated with Kt/V (OR, 0.600; CI, 0.543-0.664; P < 0.0001), and hematocrit (OR, 0.964; CI, 0.959-0.970; P < 0.0001). The distribution of DeltaBW was normal in shape and in about 22% of patients the range was from 4.0% to 4.9%. There was a significant positive relationship between the prevalence of hypertension and DeltaBW (R(2) = 0.8549). The higher the DeltaBW, the more the prescription rate of antihypertensive drugs increased (R(2) = 0.9102). Results showed that the prevalence of hypertension was significantly associated with volume excess and serum levels of albumin, calcium, and phosphorous in chronic HD patients. Despite the high prescription rate of antihypertensive drugs, control of blood pressure remains unsatisfactory.

Which Parameter Is More Influential on the Development of Arteriosclerosis in Hemodialysis Patients?

Arteriosclerosis is characterized by stiffening of arteries. The incremental elastic modulus (Einc) measurement is a good marker of arterial wall stiffness. Arteriosclerosis is characterized by stiffening of arteries. Metabolic, inflammatory, and hemodynamic alterations cause structural changes and vascular complications in end‐stage renal disease. The aim of the present study was to evaluate the factors that may affect the development of arteriosclerosis by measurement of Einc in hemodialysis (HD) patients. Thirty‐two patients (16 men and 16 women) on chronic HD with a mean age of 42.2 ± 19.3 (range, 15–80) were included in the study. The carotid Einc was measured to determine arteriosclerosis by high‐resolution echo‐tracking system. Einc measurement was calculated from transcutaneous measurements of carotid arterial internal diameter and wall thickness and carotid pulse pressure. Common carotid compliance (CCC) and distensibility (CCD) were determined from changes in carotid artery diameter during systole and simultaneously measured carotid pulse pressure. Serum levels of calcium (Ca), phosphorus (P), parathormone (PTH), ferritin, C‐reactive protein (CRP), predialysis systolic blood pressure (SBP), predialysis diastolic blood pressure (DBP), pulse pressure (PP), age, HD duration, CCC, and CCD were correlated with Einc in all patients. A significant positive correlation was found between Einc and age (r = 0.40, p &lt; 0.02), SBP (r = 0.39, p &lt; 0.02), PP (r = 0.40, p &lt; 0.02), Ca (r = 0.43, p &lt; 0.01), CRP (r = 0.38, p &lt; 0.02). As expected, Einc was correlated inversely with CCD (r = −0.77, p &lt; 0.0001). The correlation between Einc and HD duration, DBP, ferritin, P, PTH, and CCC was not significant. In conclusion, the stiffening of carotid artery in HD patients is related not only to hemodynamic changes (increased SBP and PP) but also to metabolic (increased Ca) and inflammatory (increased CRP) responses. Carotid Einc is an accepted independent risk factor for cardiovascular mortality. Because of the positive correlation between Einc and serum Ca, vitamin D and Ca‐containing P binder should be used carefully in HD patients.

Hemodialysis-associated hypertension: pathophysiology and therapy.

The majority of end-stage renal disease (ESRD) patients are hypertensive. Hypertension in the hemodialysis patient population is multifactorial. Further, hypertension is associated with an increased risk for left ventricular hypertrophy, coronary artery disease, congestive heart failure, cerebrovascular complications, and mortality. Antihypertensive medications alone do not adequately control blood pressure (BP) in hemodialysis patients. There are, however, several therapeutic options available to normalize BP in these patients, often without the need for additional drug therapy (eg, long, slow hemodialysis; short, daily hemodialysis; nocturnal hemodialysis; or, most effectively, dietary salt and fluid restriction in combination with reduction of dialysate sodium concentration). Optimal BP in dialysis patients is not different from recommendations for the general population, even though definite evidence is not yet available. Predialysis systolic and diastolic BPs are of particular importance. Left ventricular mass correlates with predialysis systolic BP. Survival is better in hemodialysis patients with a mean arterial pressure below 99 mm Hg as compared with those with higher BP. Low predialysis systolic BP (<110 mm Hg) and low predialysis diastolic BP (<70 mm Hg) are associated with increased mortality, primarily because of severe congestive heart failure or coronary artery disease. Patients that experience repeated intradialytic hypotensive episodes should also be viewed with caution, and predialytic BP values should be reevaluated. A possible treatment option for these patients may be slow, long hemodialysis; short, daily hemodialysis; or nocturnal hemodialysis. Among the antihypertensive agents currently available, angiotensin-converting enzyme (ACE) inhibitors appear to have the greatest ability to reduce left ventricular mass. Pressure load can be satisfactorily determined by using the average value of predialysis BP measurements over 1 month. In selected hemodialysis patients, interdialytic ambulatory blood pressure monitoring (ABPM) may help to determine if the patient is in fact hypertensive. In addition, ABPM provides important information about the change in BP between day and night. Regular home BP monitoring, yearly echocardiography, and treatment of traditional risk factors for cardiovascular disease are recommended.

Effects of recombinant erythropoietin therapy on circulating endothelial markers in hemodialysis patients.

Effects of a 4-week course of recombinant human erythropoietin (rHuEpo) therapy on four circulating endothelium-derived cardiovascular risk markers were studied in 20 patients receiving maintenance hemodialysis in relation to surrogates of chronic inflammation, liver function, and arterial blood pressure. Soluble intercellular adhesion molecule-1 (sICAM-1), antigens of plasminogen activator inhibitor-1 (PAI-1:Ag) and von Willebrand factor (vWF:Ag), and soluble thrombomodulin (sTM) were determined by immunoenzymatic assays. C-reactive protein; alpha1 acid-glycoprotein; alpha1-antitrypsin; immunoglobulin M, A, and G; interleukin-6; lipoprotein(a); fibrinogen; total protein; albumin; total cholesterol; hepatitis B and C markers; liver enzymes; prothrombin time; and phosphorus were measured by routine methods. The rHuEpo treatment resulted in a 25% increase in sICAM-1 (Wilcoxon's p = 0.001), a 50% increase in PAI-1:Ag (p = 0.004), a 15% increase in sTM (p = 0.002), and did not change vWF:Ag levels. The increase in sICAM-1 concentration directly correlated with that of PAI-1:Ag (Spearman's rho = 0.483, p = 0.031). The rHuEpo-induced increases in hemoglobin, platelets, and pre-dialysis diastolic blood pressure levels did not correlate with the increments in the endothelial markers studied. In conclusion, short-term rHuEpo therapy activates vascular endothelium in patients receiving maintenance hemodialysis. This specific effect may influence cardiovascular risk.

Prediction of left ventricular geometry by clinic, pre-dialysis and 24-h ambulatory BP monitoring in hemodialysis patients: CREED investigators.

Arterial hypertension is an established risk factor for left ventricular hypertrophy (LVH) in the uremic population. However, whether 24-h monitoring is a better predictor of LVH than clinic blood pressure and routine pre-dialysis measurements in these patients is still undefined. This problem was studied in 64 nondiabetic hemodialysis patients without heart failure. The echocardiographic study as well as the clinic and 24-h ambulatory blood pressure (BP) measurements were performed during the day off-dialysis. Pre-dialysis arterial pressure was calculated as the average value of the 12 routine recordings taken during the month preceding the study. In multivariate models, including also sex, body mass index, hematocrit and serum cholesterol, pre-dialysis systolic, diastolic and pulse pressures were the only independent BP determinants of heart geometry. Twenty-four hour ambulatory BP monitoring (ABPM) did add significant (but weak) information to the prediction of left ventricular internal dimension, i.e. it increased by 9% (P = 0.01) the variance already explained by pre-dialysis diastolic BP and other significant covariates. However, 24-h ABPM did not add any significant and independent explanatory information to the corresponding pre-dialysis measurements for the posterior wall and interventricular septum measurements, and for left ventricular mass (-0.6 to +3.9%; average +1.1%). In dialysis patients, pre-dialysis BP is at least as strong a predictor of left ventricular mass as 24-h ambulatory monitoring. Thus, the average of 12 routine pre-dialysis measurements may be used to predict heart geometry in dialysis patients without any loss of information in comparison with 24-h ambulatory monitoring.

Body Fluid Spaces and Blood Pressure in Hemodialysis Patients During Amelioration of Anemia With Erythropoietin

Blood pressure (BP) may increase in hemodialysis patients during treatment of anemia with recombinant human erythropoietin (r-HuEPO). Since fluid volume is a determinant of BP in dialysis patients, changes in body fluid spaces during r-HuEPO therapy could affect BP. Thus, 51Cr-labeled red blood cell (RBC) volume, inulin extracellular fluid (ECF) volume, and urea total body water (TBW), as well as cardiac output, plasma renin activity (PRA), and plasma aldosterone concentration were determined postdialysis before and after r-HuEPO therapy in patients in whom changes in BP could be managed by ultrafiltration alone. Eleven patients entered the study: one had a renal transplant and two required addition of antihypertensive drug therapy and were excluded; eight, of whom two required antihypertensive drug therapy following the study, were included in the analyses. Results revealed an increase in predialysis hemoglobin from 67 to 113 g/L (6.7 to 11.3 g/dL) (P = 0.001) during 18 +/- 6 weeks of therapy. Predialysis diastolic BP increased from 80 to 85 mm Hg (P = 0.07), while postdialysis diastolic BP was unchanged at 73 mm Hg. 51Cr-RBC volume increased, from 0.7 to 1.3 L (P = 0.004). ECF tended to decrease, from 13.7 to 10.8 L (P = 0.064), while TBW decreased to a similar extent, but not significantly, 34.3 to 31.2 L (P = 0.16). Postdialysis ECF volume was positively correlated with mean arterial BP at baseline (r = 0.89, P = 0.007) and after therapy (r = 0.74, P = 0.035). However, the regression lines for this relationship were different (P = 0.022) before and after therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood pressure control during maintenance haemodialysis with isonatric (high sodium) dialysate

Summary Isonatric (high sodium) dialysis has several advantages, including relative freedom from cramps. The diastolic blood pressures and body weights of nine originally hypertensive patients on maintenance haemodialysis have been recorded for 15 months throughout alternating periods on isonatric (145 mEq/l) and low (132·5 mEq/l) dialysate sodium concentration. Isonatric dialysis resulted in a temporary 1-2 kg increase in mean pre-dialysis weight, requiring increased ultrafiltration. This coincided with a slight increase in mean pre-dialysis diastolic blood pressure which was corrected when post-dialysis body weights were lowered to compensate for the increased weight gain between dialyses. Once the ‘ideal’ individual post-dialysis body weight for each patient was established, pre-dialysis diastolic pressures less than 90 mmHg were achieved routinely. Ten subsequent patients who have never received low sodium dialysis also have well controlled pressures. These findings are contrary to the orthodox view that low sodium dialysis is mandatory to avoid hypertension.