Predialysis Systolic Blood Pressure Research Articles

Visit-to-visit systolic blood pressure variability associates with vascular thrombosis in hemodialysis patients

Abstract Background Blood pressure variability (BPV) is an independent risk factor for cardiovascular events and death in general population. Hemodialysis patients have higher BPV and higher vascular events than general population. However, the impact of BPV on vascular events of hemodialysis patients is not clear. Purpose To determine the association of BPV with vascular outcomes in patients on maintenance hemodialysis. Method In this prospective multi-center study, we enrolled 927 maintenance hemodialysis patients from Jan, 2017 to Dec, 2017. We used the coefficient of variation (CV) and the variance independent of mean (VIM) of predialysis systolic blood pressure (SBP) derived from the first 3 months (36 dialysis sessions) after enrollment as the metrics of BPV. Patients were prospectively followed at 3-month interval. Outcomes included death, systemic vascular thrombosis (nonfatal myocardial infarction, ischemic stroke, and acute limb ischemia), and dialysis vascular access thrombosis. Results In all, 707 subjects with at least 20 measurements were included in the analysis. Patients' mean age was 66 years and 50% of patients were male. Baseline factors associated higher BPV included diabetes, high co-morbidity scores, low albumin, high systolic and diastolic blood pressure. The mean pre-dialysis SBP CV was 10.9% and VIM was 28.9%. The median follow-up duration was 2.5 years, during which 103 deaths, 81 systemic vascular thrombosis, and 155 dialysis access thrombosis occurred. In unadjusted model, we found that the highest BPV tertile had a 52% increased risk of vascular thrombosis than the lowest BPV tertile (HR=1.52, 95% CI 1.23–1.86, P<0.001). After multivariable adjustment (including age, diabetes, co-morbidity score, albumin, baseline systolic and diastolic BP), this association remained statistically significant (HR=1.47, 95% CI=1.18–1.84, P=0.001). Systolic BPV was associated with either systemic vascular thrombosis (HR=1.44, 95% CI=1.08–1.93, P=0.01) or dialysis vascular access thrombosis (HR=1.55, 95% CI=1.16–1.82, P=0.001). Conclusion In the cohort of patients on maintenance hemodialysis, high pre-dialysis systolic BPV was associated a higher risk of vascular thrombosis events, both for systemic vascular thrombosis and dialysis vascular access thrombosis. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): National Taiwan University Hsinchu Branch

Calcium channel blockers for people with chronic kidney disease requiring dialysis.

Calcium channel blockers (CCBs) are used to manage hypertension which is highly prevalent among people with chronic kidney disease (CKD). The treatment for hypertension is particularly challenging in people undergoing dialysis.To assess the benefits and harms of calcium channel blockers in patients with chronic kidney disease requiring dialysis.We searched the Cochrane Kidney and Transplant Register of Studies to 27 April 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.All randomised controlled trials (RCTs) and quasi-RCTs that compared any type of CCB with other CCB, different doses of the same CCB, other antihypertensives, control or placebo were included. The minimum study duration was 12 weeks.Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random-effects model and results expressed as risk ratio (RR), risk difference (RD) or mean difference (MD) with 95% confidence intervals (CI).This review included 13 studies (24 reports) randomising 1459 participants treated with long-term haemodialysis. Nine studies were included in the meta-analysis (622 participants). No studies were performed in children or in those undergoing peritoneal dialysis. Overall, risk of bias was assessed as unclear to high across most domains. Random sequence generation and allocation concealment were at low risk of bias in eight and one studies, respectively. Two studies reported low risk methods for blinding of participants and investigators, and outcome assessment was blinded in 10 studies. Three studies were at low risk of attrition bias, eight studies were at low risk of selective reporting bias, and five studies were at low risk of other potential sources of bias. Overall, the certainty of the evidence was low to very low for all outcomes. No events were reported for cardiovascular death in any of the comparisons. Other side effects were rarely reported and studies were not designed to measure costs. Five studies (451 randomised adults) compared dihydropyridine CCBs to placebo or no treatment. Dihydropyridine CCBs may decrease predialysis systolic (1 study, 39 participants: MD -27.00 mmHg, 95% CI -43.33 to -10.67; low certainty evidence) and diastolic blood pressure level (2 studies, 76 participants; MD -13.56 mmHg, 95% CI -19.65 to -7.48; I2 = 0%, low certainty evidence) compared to placebo or no treatment. Dihydropyridine CCBs may make little or no difference to occurrence of intradialytic hypotension (2 studies, 287 participants; RR 0.54, 95% CI 0.25 to 1.15; I2 = 0%, low certainty evidence) compared to placebo or no treatment. Other side effects were not reported. Eight studies (1037 randomised adults) compared dihydropyridine CCBs to other antihypertensives. Dihydropyridine CCBs may make little or no difference to predialysis systolic (4 studies, 180 participants: MD 2.44 mmHg, 95% CI -3.74 to 8.62; I2 = 0%, low certainty evidence) and diastolic blood pressure (4 studies, 180 participants: MD 1.49 mmHg, 95% CI -2.23 to 5.21; I2 = 0%, low certainty evidence) compared to other antihypertensives. There was no evidence of a difference in the occurrence of intradialytic hypotension (1 study, 92 participants: RR 2.88, 95% CI 0.12 to 68.79; very low certainty evidence) between dihydropyridine CCBs to other antihypertensives. Other side effects were not reported. Dihydropyridine CCB may make little or no difference to predialysis systolic (1 study, 40 participants: MD -4 mmHg, 95% CI -11.99 to 3.99; low certainty evidence) and diastolic blood pressure (1 study, 40 participants: MD -3.00 mmHg, 95% CI -7.06 to 1.06; low certainty evidence) compared to non-dihydropyridine CCB. There was no evidence of a difference in other side effects (1 study, 40 participants: RR 0.13, 95% CI 0.01 to 2.36; very low certainty evidence) between dihydropyridine CCB and non-dihydropyridine CCB. Intradialytic hypotension was not reported.The benefits of CCBs over other antihypertensives on predialysis blood pressure levels and intradialytic hypotension among people with CKD who required haemodialysis were uncertain. Effects of CCBs on other side effects and cardiovascular death also remain uncertain. Dihydropyridine CCBs may decrease predialysis systolic and diastolic blood pressure level compared to placebo or no treatment. No studies were identified in children or peritoneal dialysis. Available studies have not been designed to measure the effects on costs. The shortcomings of the studies were that they recruited very few participants, had few events, had very short follow-up periods, some outcomes were not reported, and the reporting of outcomes such as changes in blood pressure was not done uniformly across studies. Well-designed RCTs, conducted in both adults and children with CKD requiring both haemodialysis and peritoneal dialysis, evaluating both dihydropyridine and non-dihydropyridine CCBs against other antihypertensives are required. Future research should be focused on outcomes relevant to patients (including death and cardiovascular disease), blood pressure changes, risk of side effects and healthcare costs to assist decision-making in clinical practice.

Optimal blood pressure for the minimum all-cause mortality in Chinese ESRD patients on maintenance hemodialysis

Blood pressure (BP) is a known prognostic marker for mortality in patients on maintenance hemodialysis (MHD). However, definition of the BP and its optimal values vary essentially among different MHD populations. Our purpose was to clarify these important clinical parameters in a Chinese MHD cohort. Accordingly, we reviewed the available records of patients on regular MHD during the past 10 years and made a comparison between the deceased (n=81) and survival ones (n=131). Multiple logistic regression and Kaplan–Meier survival analysis were used to examine the effect of BP on mortality and long-term survival, respectively. The all-cause mortality in our patients was 38.2%, in which 49.4% was from cardio-cerebrovascular deaths. Using the multiple logistic regression, we found that the sitting (the same definition hereafter) pre-dialysis systolic BP (SBP) was significantly associated with both the all-cause mortality and cardio-cerebrovascular deaths exclusively in patients of 60–80 years. Moreover, a pre-dialysis SBP of 140–160 mmHg in these patients had the minimum all-cause mortality (23.5%) against that conferred by either a lower (42.1%) or higher SBP value (61.5%). This observation was further confirmed by the Kaplan–Meier survival analysis. As fresh gain to the practice of hemodialysis, our report revealed that BP worked in a time-dependent way among a Chinese MHD cohort and highlighted a U-shaped association between the pre-dialysis SBP and all-cause mortality. These findings may hence help to obtain optimal BP control for better survival and lend some prognostic insight into mortality in these MHD patients.

Interdialytic blood pressure variability and the risk of stroke in maintenance hemodialysis patients.

Studies on nondialysis populations have linked visit-to-visit blood pressure (BP) variability (BPV) to cerebrovascular events and mortality. In view of the high prevalence of hypertension in hemodialysis patients, the predictive values of numerous factors for stroke, especially visit-to-visit BPV, were evaluated in this prospective cohort study.A total of 151 patients were enrolled in this study. The demographic features and various laboratory parameters were analyzed. At each routine hemodialysis visit, the predialysis, intradialysis, and post-dialysis BP measurements were systematically performed. We defined BPV using 4 metrics: standard deviation of the BP, coefficient of variation, average real variability (ARV), and variability independent of mean (VIM). Differences in the predialysis BPs from one treatment to the next (ie, interdialytic variability) and differences in the BPs from predialysis to post-dialysis (ie, intradialytic variability) were both studied in this work.Twenty-one patients developed stroke and 25 patients died. The multivariate Cox proportional hazards regression model revealed a significant relationship between stroke and the interdialytic BPV (both predialysis systolic BP variability and predialysis diastolic BP variability) and low-density lipoprotein-cholesterol (LDL-C).Our results indicate that a high interdialytic BPV is associated with an increased risk for stroke that is independent of several factors, including age, sex, antihypertensive medication use, and mean BP over time. There is potential that the optimal treatment goal for hemodialysis patients may be to reduce the interdialytic BPV rather than either the mean BP or the intradialytic BPV.

Intradialytic Hypotension and Cardiac Arrhythmias in Patients Undergoing Maintenance Hemodialysis: Results from the Monitoring in Dialysis Study.

Patients receiving maintenance hemodialysis (HD) have a high incidence of cardiac events, including arrhythmia and sudden death. Intradialytic hypotension (IDH) is a common complication of HD and is associated with development of reduced myocardial perfusion, a potential risk factor for arrhythmia. We analyzed data from the Monitoring in Dialysis study, which used implantable loop recorders to detect and continuously monitor electrocardiographic data from patients on maintenance HD (n=66 from the United States and India) over a 6-month period (n=4720 sessions). Negative binomial mixed effects regression was used to test the association of IDH20 (decline in systolic BP >20 mm Hg from predialysis systolic BP) and IDH0-20 (decline in systolic BP 0-20 mm Hg from predialysis systolic BP) with clinically significant arrhythmia (bradycardia≤40 bpm for ≥6 seconds, asystole≥3 seconds, ventricular tachycardia ≥130 bpm for ≥30 seconds, or patient-marked events) during HD. The median age of participants was 58 (25th-75th percentile, 49-66) years; 70% were male; and 65% were from the United States. IDH occurred in 2251 (48%) of the 4720 HD sessions analyzed, whereas IDH0-20 occurred during 1773 sessions (38%). The number of sessions complicated by least one intradialytic clinically significant arrhythmia was 27 (1.2%) where IDH20 occurred and 15 (0.8%) where IDH0-20 occurred. Participants who experienced IDH20 (versus not) had a nine-fold greater rate of developing an intradialytic clinically significant arrhythmia (incidence rate ratio, 9.4; 95% confidence interval, 3.0 to 29.4), whereas IDH0-20 was associated with a seven-fold higher rate (incidence rate ratio, 7.2; 95% confidence interval, 2.1 to 25.4). IDH is common in patients on maintenance HD and is associated with a greater risk of developing intradialytic clinically significant arrhythmia.

Uncertainties in BP management in dialysis patients.

Hypertension in dialysis patients is extremely common. In this article, we review the current evidence for blood pressure (BP) goals in hemodialysis patients, and consider the effectiveness of interventions by which BP may be lowered, including manipulation of dietary and dialysate sodium; optimization of extracellular water; prolongation of dialysis time; and antihypertensive medication. Although two meta-analyses suggest lowering BP using antihypertensive drugs might be beneficial in reducing cardiovascular events and mortality, there are insufficient rigorously designed trials in hypertensive hemodialysis populations to determine preferred antihypertensive drug classes. We suggest aiming for predialysis systolic BP between 130 and 159mm Hg, while at the same time acknowledge the significant limitations of the data upon which it is based. We conclude by summarizing current knowledge as regards management of hypertension in the peritoneal dialysis population and make recommendations for future research in this field.

Postdialysis blood pressure is a better predictor of mortality than predialysis blood pressure in Japanese hemodialysis patients: the Japan Dialysis Outcomes and Practice Patterns Study.

Blood pressure (BP) is reportedly a predictor of mortality in hemodialysis (HD) patients; however, it is unclear whether pre- or postdialysis BP has greater predictive power. To evaluate the association of pre- and postdialysis BP with patient survival in Japanese HD patients, we enrolled the entire phase 3 and 4 Japan Dialysis Outcomes and Practice Patterns Study populations. Among 3176 patients, 486 were excluded because of missing data. The remaining 2690 patients were divided into five groups according to pre- or postdialysis systolic BP (SBP): <100, 100-119, 120-139, 140-159, and ≥160 mmHg; diastolic BP (DBP): <60, 60-79, 80-89, 90-99, and ≥100 mmHg; or pulse pressure (PP): <50, 50-59, 60-69, 70-79, and ≥80 mmHg. The hazard ratios for all-cause and cardiovascular mortalities were estimated according to pre- and postdialysis SBP, DBP, and PP using a Cox proportional hazards model. During the follow-up period, 495 and 193 subjects died because of any cause and cardiovascular disease (CVD), respectively. In the multivariable-adjusted Cox proportional hazards model, U-shaped associations of postdialysis SBP and PP with mortality rates were observed, but no significant associations were observed with predialysis SBP or PP. A stratified analysis showed significant interactions between history of CVD and postdialysis SBP with all-cause and cardiovascular mortality. Compared with predialysis values, postdialysis SBP and PP are better predictors of all-cause and cardiovascular mortality, showing U-shaped associations with these outcomes in Japanese HD patients.

Fluid overload is associated with use of a higher number of antihypertensive drugs in hemodialysis patients.

Hypertension is multifactorial, highly prevalent in the hemodialysis (HD) population and its adequate control requires, in addition to adequate volume management, often the use of multiple antihypertensive drugs. We aimed to describe the use of antihypertensive agents in a group of HD patients and to evaluate the factors associated with the use of multiple classes (≥3) of antihypertensives. We analyzed the baseline data from the HDFit study. Clinically stable patients with HD vintage between 3 and 24 months without any severe mobility limitation were recruited from sites throughout southern Brazil. Fluid status was measured pre-dialysis with the Body Composition Monitor (BCM; Fresenius, Germany). Fluid overload (FO) was considered when the overhydration index (OH) was greater than 7% of extracellular water (OH/ECW > 7%) and overweight was defined as a body mass index (BMI) greater than 25 kg/m2 . Prescriptions of antihypertensive drugs were obtained from participants' reports and medical records. Logistic regression was employed to determine factors associated with excessive use of antihypertensive medication (≥3 classes). Of 195 studied patients, 171 with complete data were included (70% male, 53 ± 15 years old, 57% of them with FO). Pre-dialysis systolic blood pressure (SBP) was 150 ± 24 mmHg and patients used a median of 2 (1-3) antihypertensive drugs. Vasodilators (20%) were of lowest prevalence, use of other classes varied from 40% to 53%. Sixty-two (36%) subjects used ≥3 classes and presented a higher prevalence of diabetes and FO, lower prevalence of overweight, and higher SBP. In a logistic regression model age, BMI <25 kg/m2 , and OH/ECW > 7% were associated with excessive drug use. More than one-third of participants used ≥3 classes of antihypertensive drugs, and it was associated with older age, BMI <25 kg/m2 and FO. Strategies that better manage FO may aid better blood pressure control and avoid the use of multiple antihypertensive medications.

Ambulatory Blood Pressure Monitoring in Hemodialysis Patients with Intradialytic Hypertension

Introduction. It has not yet been clear whether intradialytic hypertension (IDHN) translates into the presence of high BP between dialysis sessions or not. In this study, we aimed to perform interdialytic ambulatory blood pressure monitoring (ABPM) in patients with IDHN to find whether high BP persists at home. Methods. In this case-control study, ABPM was performed during a 44-hours interdialytic period in patients on maintenance hemodialysis (HD) with pre-dialysis systolic BP (SBP) above 130 mmHg. Bland- Altman graphs were used to investigate the magnitude of the difference between the results of ABPM records and intradialytic BP measurements in patients with and without IDHN. Results. A total of 56 patients were enrolled in our study (29 in the IDHN group and 27 in the control group). The average of the pre-dialysis SBP in 6 consecutive HD treatments was 146.6 ± 11.36 vs. 146.8 ± 12.1 mmHg in IDHN and control group, respectively (P > .05). Mean post-dialysis SBP was 154.45 ± 12.6 mmHg in the IDHN group and 136.76 ± 11.50 in the control group (P < .001). Mean ± SD of 44-hour SBP was 157.31 ± 20.27 mmHg in the IDHN group, which was significantly higher than that in the control group (146.5 ± 16.67 mmHg, P < .05). No significant differences were seen in the average of interdialytic weights gain between the two groups. Compared to the pre-dialysis SBP, using Bland- Altman graphs, the post-dialysis SBP (bias of 3.5 mmHg) had closer readings to the daytime SBP in the IDHN group. Conclusion. Patients with IDHN had higher interdialytic BPs. Among BPs taken during HD in patients with IDHN, post-dialysis SBP had the lowest difference with the daytime SBP taken by ABPM.

SAT-217 COMPLICATIONS OF ARTERIO-VENOUS FISTULA AS A VASCULAR ACCESS IN HEMODIALYSIS PATIENTS- A HOSPITAL BASED STUDY

Vascular access is required for hemodialysis and arterio-venous fistula is the preferred access. It is the life line for patients on hemodialysis. Various guidelines have recommended monitoring and surveillance of arterio-venous fistula as a standard of care. Clinical examination can detect most of the complications. This study looked into various complications of arterio-venous fistula as a vascular access in hemodialysis patients. The study was conducted in the hemodialysis unit of a Teaching Hospital in Central Nepal from January 2017 till December 2017. Ethical clearance was taken from IRC, Nepal Medical College. Patients undergoing hemodialysis for at least 3 months were enrolled in the study. After informed and written consent, clinical examination and colour doppler ultrasound of the arterio-venous fistula was done. The physicians performing the clinical examination and the colour doppler examination were blinded to remove bias. Clinical, socio-demographic and biochemical parameters were recorded. Statistical analysis was done using Statistical Package for the Social Sciences software version 20 and Epi-info software version 7. Total study population was 102. The patency of arterio-venous fistula was seen in 91%. Primary failure was present in 15.7%. The different complications observed were pseudoaneurysm (16.7%), thrombus formation (17.6%), venous outflow stenosis (9.8%), juxta-anastomostic stenosis (8.8%), central vein stenosis (8.8%), extravascular hematoma (4.9%), megafistula (4.9%) and infection (2.9%). Sensitivity and specificity of clinical examination as compared to colour doppler ultrasound was 88% and 95% which varied with different complications. Secondary failure rate of arterio-venous fistula was 13.7%. The average blood flow rate across the AVF in the complications group was much higher (2183 ml/min) and was statistically significant (p=0.002). Female sex, high venous pressure, history of primary failure of AVF, Tuberculosis, higher pre dialysis systolic and diastolic blood pressure, low BMI and secondary AVF failure were statistically significant for complications associated with AVF. Presence of strong palpable pulsations on clinical examination of AVF was statistically significant parameter which identified complications of AVF.TableShowing Validity of clinical examination as compared to colour doppler ultrasound examination in detecting complications of AVF.ComplicationsSensitivity (%)(95% CI)Specificity (%)(95% CI)Positive Predictive Value (%) (95% CI)Negative Predictive Value (%) (95% CI)Thrombus87.5 (61.6-98.4)95.3 (88.5-98.7)77.7 (56.9-90.2)97.6 (91.8-99.3)Pseudoaneurysm71.4 (47.8-88.7)97.5 (91.3-99.7)88.2 (65.0-96.0)92.9 (87.1-96.2)Stenosis95.4 (77.1-99.8)91.2 (82.8-96.4)75 (59.5-85.9)98.6 (91.4-99.8)Infection40 (5.27-85.3)98.9 (94.3-99.7)66.6 (17.7-94.8)96.9 (93.9-98.5)Hematoma40 (5.3-85.4)96.9 (91.2-99.3)40 (12.4-75.8)96.9 (93.8-98.4) Open table in a new tab Arterio-venous fistula is associated with higher rate of complications. Clinical examination is highly sensitive and specific but underutilized tool to detect the complications of arterio-venous fistula. Colour doppler ultrasonographic examination should also be done to look into hemodynamics of associated AVF and managed accordingly. Monitoring and surveillance of AVF should be performed as a standard of care in every hemodialysis centre.

Association of all-cause mortality with pre-dialysis systolic blood pressure and its peridialytic change in chronic hemodialysis patients.

BackgroundPre-dialysis systolic blood pressure (pre-HD SBP) and peridialytic SBP change have been associated with morbidity and mortality among hemodialysis (HD) patients in previous studies, but the nature of their interaction is not well understood.MethodsWe analyzed pre-HD SBP and peridialytic SBP change (calculated as post-HD SBP minus pre-HD SBP) between January 2001 and December 2012 in HD patients treated in US Fresenius Medical Care facilities. The baseline period was defined as Months 4–6 after HD initiation, and all-cause mortality was noted during follow-up. Only patients who survived baseline and had no missing covariates were included. Censoring events were renal transplantation, modality change or study end. We fitted a Cox proportional hazard model with a bivariate spline functions for the primary predictors (pre-HD SBP and peridialytic SBP change) with adjustment for age, gender, race, diabetes, access-type, relative interdialytic weight gain, body mass index, albumin, equilibrated normalized protein catabolic rate and ultrafiltration rate.ResultsA total of 172 199 patients were included. Mean age was 62.1 years, 61.6% were white and 55% were male. During a median follow-up of 25.0 months, 73 529 patients (42.7%) died. We found that a peridialytic SBP rise combined with high pre-HD SBP was associated with higher mortality. In contrast, when concurrent with low pre-HD SBP, a peridialytic SBP rise was associated with better survival.ConclusionThe association of pre-HD and peridialytic SBP change with mortality is complex. Our findings call for a joint, not isolated, interpretation of pre-HD SBP and peridialytic SBP change.

Target blood pressure in patients with chronic kidney disease on maintenance hemodialysis using ambulatory blood pressure monitoring for 72 h – A prospective observational study

Background and Aim: The target blood pressure (BP) in CKD patients on hemodialysis (HD) remains a dilemma. We aimed to study the BP value most representative of the presence or absence/control of hypertension in CKD patients on HD, and how well could ambulatory BP monitoring (ABPM) predict the presence of hypertension. Materials and Methods: A total of 39 patients with CKD on twice-weekly HD were included in the study. BP was recorded with the help of the sphygmomanometer installed in the HD machine at regular intervals, and the same was compared with ABPM continuously for 72 h during the interdialytic period. Bland–Altman analysis and receiver operating characteristic curve were analyzed. Results: The difference between the mean predialysis systolic blood pressure (SBP) and mean ambulatory SBP was 9.09 mmHg (95% confidence interval [CI], -22.92 to + 41.099 mmHg); however, the difference of 4.86 mmHg (95% CI, -17.886 to + 27.606 mmHg) between the mean diastolic ABPM reading and the mean predialysis diastolic BP did not achieve significance. Conclusion: The data suggest that predialysis office SBP invariably overestimates BP and should not be targeted as a BP goal, as it could lead to intradialytic hypotension. For any given SBP, the postdialysis value is more specific in diagnosing hypertension, thereby reflecting a more significant cardiovascular load. To our knowledge this is the first study to use ABPM continuously during the interdialytic period for 72 h.

Is high-volume post-dilution haemodiafiltration associated with risk of fluid volume imbalance? A national multicentre cross-sectional cohort study.

BackgroundFluid overload is frequent among hemodialysis (HD) patients. Dialysis therapy itself may favor sodium imbalance from sodium dialysate prescription. As on-line hemodiafiltration (OL-HDF) requires large amounts of dialysate infusion, this technique can expose to fluid accumulation in case of a positive sodium gradient between dialysate and plasma. To evaluate this risk, we have analyzed and compared the fluid status of patients treated with HD or OL-HDF in French NephroCare centers.MethodThis is a cross-sectional and retrospective analysis of prevalent dialysis patients. Data were extracted from the EUCLID5 data base. Patients were split in 2 groups (HD and OL-HDF) and compared as whole group or matched patients for fluid status criteria including predialysis relative fluid overload (RelFO%) status from the BCM®.Results2242 patients (age 71 years; female: 39%; vintage: 38 months; Charlson index: 6) were studied. 58% of the cohort were prescribed post-dilution OL-HDF. Comparing the HD and OL-HDF groups, there was no difference between HD and OL-HDF patients regarding the predialysis systolic BP, the interdialytic weight gain, the dialysate-plasma sodium gradient, and the predialysis RelFO%. The stepwise logistic regression did not find dialysis modality (HD or OL-HDF) associated with fluid overload or high predialysis systolic blood pressure. In OL-HDF patients, monthly average convective or weekly infusion volumes per session were not related with the presence of fluid overload.ConclusionsIn this cross-sectional study we did not find association between the use of post-dilution OL-HDF and markers of fluid volume excess. Aligned dialysis fluid sodium concentrations to patient predialysis plasma sodium and regular monitoring of fluid volume status by bioimpedance spectroscopy may have been helpful to manage adequately the fluid status in both OL-HDF and HD patients.

Effectiveness of bioimpedance spectroscopy on dry weight (DW) measurement in haemodialysis patients: a systematic review

Aim To review the effects of bioimpedance spectroscopy (BIS) to measure dry weight (DW) in haemodialysis (HD)patients when compared to clinical examination. Methods The review was conducted according to the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MasARI). Meta-analysis was performed using Review Manager 5 software. The search was limited to English language papers published from 2005 to 2017. A standard JBI three-step search strategy was used. We searched all quantitative studies from major databases for investigations of the BIS for measuring DW in HD patients. Results A total of four randomised controlled trials (RCTs) met the inclusion criteria. These studies all involved patients with end-stage kidney disease (ESKD) receiving HD and the comparison of BIS versus physician’s clinical judgement using cardiovascular parameters and mortality outcomes. The meta-analysis of BIS when compared with clinical judgement found no significant differences in the reduction of the mortality rate, hospitalisation rate or other cardiovascular parameters after 12 months of the intervention; only significant improvement in pre-dialysis systolic BP (WMD –5.41, 95% CI –9.00 to –1.82; p=0.003) was reported. However, individual RCTs found that BIS is an effective intervention for HD patients in the reduction of the mortality rate (HR 0.100, 95% CI, 0.013 to 0.805; p=0.04) after 2.5 years of the intervention. Conclusion The small number of participants and restricted participant selection criteria all has considerable impact with regard to generalising these findings to wider HD populations.

Blood Pressure and Incident Atrial Fibrillation in Older Patients Initiating Hemodialysis.

We examined the association of predialysis systolic and diastolic BP and intradialytic hypotension with incident atrial fibrillation in older patients initiating hemodialysis. We used the US Renal Data System linked to the records of a large dialysis provider to identify patients aged ≥67 years initiating hemodialysis between January 2006 and October 2011. We examined quarterly average predialysis systolic BP, diastolic BP, and proportion of sessions with intradialytic hypotension (i.e., nadir systolic BP <90 mm Hg). We applied an extended Cox model to compute adjusted hazard ratios (HRs) of each exposure with incident atrial fibrillation. Among 17,003 patients, 3785 developed atrial fibrillation. When comparing predialysis systolic BP to a fixed reference of 140 mm Hg, lower predialysis systolic BP was associated with a higher hazard of atrial fibrillation, whereas higher systolic BP was associated with a lower hazard of atrial fibrillation. When comparing across a range of systolic BP for two hypothetical patients with similar measured covariates, the association varied by mean systolic BP: at systolic BP 190 mm Hg, each 10 mm Hg lower systolic BP was associated with lower atrial fibrillation hazard (HR, 0.94; 95% confidence interval, 0.90 to 1.00), whereas at systolic BP 140 mm Hg, a 10 mm Hg lower systolic BP was associated with a higher atrial fibrillation hazard (HR, 1.12; 95% confidence interval, 1.10 to 1.14). Lower diastolic BP was associated with higher atrial fibrillation hazards. Intradialytic hypotension was weakly associated with atrial fibrillation. In this observational study of older patients initiating hemodialysis, lower predialysis systolic BP and diastolic BP were associated with higher incidence of atrial fibrillation.

Hypertension control among euvolemic hypertensive hemodialysis patients in Malaysia: a prospective follow-up study

ObjectivesExisting literature does not provide enough information on evaluation of factors associated with pre-dialysis controlled hypertension among euvolemic hemodialysis (HD) patients. We conducted a study to evaluate the rate and factors influencing pre-dialysis controlled hypertension among euvolemic HD patients.DesignA multicenter prospective follow-up study.SettingTertiary care teaching hospital and its associated private dialysis centers.ParticipantsThis study included 145 euvolemic eligible hypertensive patients. Various sociodemographic, clinical factors and drugs were investigated and analyzed by using appropriate statistical methods to determine the factors influencing hypertension control among the study participants.ResultsOn baseline visit, the mean pre-dialysis systolic and diastolic BP (mmHg) of study participants was 161.2 ± 24. and 79.21 ± 11.8 retrospectively, and 30 (20.6%) patients were on pre-dialysis goal BP. At the end of the 6-months follow-up, the mean pre-dialysis systolic BP and diastolic BP (mmHg) of the patients was 154.6 ± 18.3 and 79.2 ± 11.8 respectively, and 42 (28.9%) were on pre-dialysis goal BP. In multivariate analysis, the use of calcium channel blockers (CCBs) was the only variable which had statistically significant association with pre-dialysis controlled hypertension at baseline (OR = 7.530, p-value = 0.001) and final (OR = 8.988, p-value < 0.001) visits.ConclusionsIn present study, the positive association observed between CCBs and controlled hypertension suggests that CCBs are effective antihypertensive drugs in the management of hypertension among euvolemic HD patients.Strengths and limitations of this studyThis study involved a group of patients from tertiary-level teaching hospital and its associated private dialysis centers of Malaysia.To the best of the authors’ knowledge, this is the first study to assess the factors influencing pre-dialysis controlled hypertension in a cohort of 145 euvolemic HD patients in a Malaysian setting.For determining the factors influencing hypertenion control multivariate analysis was conducted.Being a prospective follow-up study, the findings of the present study need to be interpreted with caution since it is limited to only 6 months follow up.Nevertheless, a multicenter study with a large sample size and longer follow up time is needed to confirm the findings of the current study.

Blood Pressure and Cognitive Decline in Prevalent Hemodialysis Patients

Background: Hypertension is associated with cognitive decline in the general population. It is unclear what impact blood pressure (BP) has on cognitive decline in patients receiving maintenance hemodialysis (HD). Methods: Using a longitudinal cohort of 314 prevalent HD patients without dementia at baseline, we examined the association of predialysis systolic BP (SBP) and diastolic BP (DBP), pulse pressure, and intradialytic SBP change (pre minus post), averaged for a month, with cognitive decline. Cognitive function was determined by a neurocognitive battery, administered yearly. Individual cognitive test results were reduced into 2 domain scores using principal components analysis (by definition mean of 0 and SD of 1), representing memory and executive function. Joint models, allowing for characterization of cognitive score slopes and including adjustment for potential confounders, were utilized to account for competing risks from death, dropout, or kidney transplantation. Results: Mean age was 62 years; 54% were men, 23% were black, and 90% had at least a high school education. During median follow-up of 2.1 years (25th–75th: 1.0–4.5), 191 had at least one follow-up test, 148 died, and 43 received kidney transplants. Low predialysis DBP and high pulse pressure were both associated with steeper executive function decline (each 10 mm Hg lower DBP = –0.03 SD [–0.01 to –0.05] per year steeper decline) in executive function (each 10 mm Hg higher pulse pressure = –0.03 SD [–0.06 to –0.01] steeper decline) but not for memory function. SBP and intradialytic change were not associated with steeper decline for either memory or executive function. Conclusions: No relationship was seen between SBP or intradialytic change in BP with cognitive decline. In prevalent HD patients, lower predialysis DBP and wider predialysis pulse pressure are associated with steeper cognitive decline in executive function but not memory.

Characteristics of visit-to-visit blood pressure variability in hemodialysis patients.

Visit-to-visit blood pressure variability (VVBPV) is an independent risk factor for cardiovascular morbidity and mortality in the general population. Hemodialysis (HD) patients have a poor prognosis due to an increased prevalence of cardiovascular disease. Intradialytic hypotension is associated with excess mortality, but whether VVBPV influences mortality is still unclear in HD patients. The present study aimed to investigate the characteristics of VVBPV in these patients. A total of 324 maintenance HD patients, who could be followed for 60 months, were recruited. We used variation independent of the mean (VIM) in pre-dialysis systolic blood pressure (pre-VIM-SBP) as an index of VVBPV. We investigated (1) the reproducibility of pre-VIM-SBP, (2) the relationship between pre-VIM-SBP and background factors, and (3) the association between pre-VIM-SBP and mortality. Pre-VIM-SBP showed significant reproducibility [intraclass correlation, 0.45 (P < 0.001)]. Higher pre-VIM-SBP was associated with less physical activity and worse left ventricular diastolic function. Higher pre-VIM-SBP was associated with a higher rate of cardiovascular deaths independent of other factors. These data suggest that VVBPV in HD patients is reproducible and associated with various background factors. VVBPV is independently correlated with cardiovascular mortality (hazard ratio: 1.166, 95% confidence interval: 1.030-1.320, P = 0.015). Further studies are necessary to confirm the mechanism of increased VVBPV and to clarify whether reducing VVBPV will improve the prognosis for HD patients.

Associations between Hemodialysis Facility Practices to Manage Fluid Volume and Intradialytic Hypotension and Patient Outcomes.

Fluid overload and intradialytic hypotension are associated with cardiovascular events and mortality in patients on hemodialysis. We investigated associations between hemodialysis facility practices related to fluid volume and intradialytic hypotension and patient outcomes. Data were analyzed from 10,250 patients in 273 facilities across 12 countries, from phase 4 of the Dialysis Outcomes and Practice Patterns Study (DOPPS; 2009-2012). Cox regression models (shared frailty) were used to estimate associations between facility practices reported by medical directors in response to the DOPPS Medical Directors Survey and all-cause and cardiovascular mortality and hospitalization, and cardiovascular events, adjusting for country, age, sex, dialysis vintage, predialysis systolic BP, cardiovascular comorbidities, diabetes, body mass index, smoking, residual kidney function, dialysis adequacy, and vascular access type. Of ten facility practices tested (chosen a priori), having a protocol that specifies how often to assess dry weight in most patients was associated with lower all-cause (hazard ratio [HR], 0.78; 99% confidence interval [99% CI], 0.64 to 0.94) and cardiovascular mortality (HR, 0.72; 99% CI, 0.55 to 0.95). Routine orthostatic BP measurement to assess dry weight was associated with lower all-cause hospitalization (HR, 0.86; 99% CI, 0.77 to 0.97) and cardiovascular events (HR, 0.85; 99% CI, 0.73 to 0.98). Routine use of lower dialysate temperature to limit or prevent intradialytic hypotension was associated with lower cardiovascular mortality (HR, 0.76; 99% CI, 0.58 to 0.98). Routine use of an online volume indicator to assess dry weight was associated with higher all-cause hospitalization (HR, 1.19; 99% CI, 1.02 to 1.38). Routine use of sodium modeling/profiling to limit or prevent intradialytic hypotension was associated with higher all-cause mortality (HR, 1.36; 99% CI, 1.14 to 1.63), cardiovascular mortality (HR, 1.34; 99% CI, 1.04 to 1.73), and cardiovascular events (HR, 1.21; 99% CI, 1.03 to 1.43). Hemodialysis facility practices relating to the management of fluid volume and intradialytic hypotension are associated with patient outcomes.

Use of body composition measurements to guide the assessment of dry weight in anuric dialysis patients: improvements in blood pressure control

PurposeFluid management using a body composition monitor (BCM) based on bioimpedance spectroscopy has been found to be beneficial for maintenance hemodialysis (MHD) patients. Our purpose was to provide a management procedure for the adjustment of post-dialysis overhydration (OHpost) and to evaluate whether this approach could improve blood pressure. MethodsPost-dialysis fluid status was assessed weekly using the BCM. The reference value of OHpost and the flow procedure for post-dialysis target weight (PDTW) adjustment were established via measurements of OHpost in 60 normotensive MHD patients. In the interventional study, we adjusted the PDTW of hypertensive patients to the optimal OHpost range, with a 0.2–0.5 kg change in PDTW per week. ResultsThis observational study included 130 anuric MHD patients, of whom 60 were in the pre-dialysis systolic blood pressure (sBPpre) < 140 mmHg group. On multivariate logistic regression analysis, we found that only OHpost was significantly associated with sBPpre ≥ 140 mmHg (odds ratio = 2.293, p = 0.000). Patients in the OHpost < −1.8 L group were mainly male and younger, and had higher post-dialysis diastolic blood pressure, ultrafiltration volume, levels of nutrition markers (serum albumin and creatinine), body mass index, and lean tissue index (LTI). On multiple stepwise regression analysis, only the change in LTI was found to be an independent predictor of OHpost [R2 0.208, β = −0.196, 95% CI (−0.296, −0.095), p < 0.001]. The reference value of OHpost was found to deviate by − 2.5–0.5 L from that of normotensive patients. At the end of the study, the systolic blood pressure of 38 patients was less than 140 mmHg after PDTW adjustment. The changes in OHpost from the initial to last adjustment were significant (t = 5.431, p < 0.001), with a substantial decrease in the sBPpre (t = 11.208, p < 0.001). ConclusionsAssessment of OHpost and LTI using a BCM with a patient-specific optimal PDTW adjustment flow can lead to significantly better control of hypertension in anuric MHD patients.