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• W2068442384 abstract "The relationship between blood pressure (BP) and clinical outcomes among hemodialysis patients is complex and incompletely understood. This study sought to assess the relationship between blood pressure changes with hemodialysis and clinical outcomes during a 6-month period. This study is a secondary analysis of the Crit-Line Intradialytic Monitoring Benefit Study, a randomized trial of 443 hemodialysis subjects, designed to determine whether blood volume monitoring reduced hospitalization. Logistic regression was used to estimate the association between BP changes with hemodialysis (Δsystolic blood pressure=postdialysis–predialysis systoic BP (SBP) and the primary outcome of non-access-related hospitalization and death. Subjects whose systolic blood pressure fell with dialysis were younger, took fewer blood pressure medications, had higher serum creatinine, and higher dry weights. After controlling for baseline characteristics, lab variables, and treatment group, subjects whose SBP remained unchanged with hemodialysis (N=150, ΔSBP -10 to 10 mm Hg) or whose SBP rose with hemodialysis (N=58, ΔSBP ≥10 mm Hg) had a higher odds of hospitalization or death compared to subjects whose SBP fell with hemodialysis (N=230, ΔSBP ≤-10 mm Hg) (odds ratio: 1.85, confidence interval: 1.15–2.98; and odds ratio: 2.17, confidence interval: 1.13-4.15). Subjects whose systolic blood pressure fell with hemodialysis had a significantly decreased risk of hospitalization or death at 6 months, suggesting that hemodynamic responses to dialysis are associated with short-term outcomes among a group of prevalent hemodialysis subjects. Further research should attempt to elucidate the mechanisms behind these findings. The relationship between blood pressure (BP) and clinical outcomes among hemodialysis patients is complex and incompletely understood. This study sought to assess the relationship between blood pressure changes with hemodialysis and clinical outcomes during a 6-month period. This study is a secondary analysis of the Crit-Line Intradialytic Monitoring Benefit Study, a randomized trial of 443 hemodialysis subjects, designed to determine whether blood volume monitoring reduced hospitalization. Logistic regression was used to estimate the association between BP changes with hemodialysis (Δsystolic blood pressure=postdialysis–predialysis systoic BP (SBP) and the primary outcome of non-access-related hospitalization and death. Subjects whose systolic blood pressure fell with dialysis were younger, took fewer blood pressure medications, had higher serum creatinine, and higher dry weights. After controlling for baseline characteristics, lab variables, and treatment group, subjects whose SBP remained unchanged with hemodialysis (N=150, ΔSBP -10 to 10 mm Hg) or whose SBP rose with hemodialysis (N=58, ΔSBP ≥10 mm Hg) had a higher odds of hospitalization or death compared to subjects whose SBP fell with hemodialysis (N=230, ΔSBP ≤-10 mm Hg) (odds ratio: 1.85, confidence interval: 1.15–2.98; and odds ratio: 2.17, confidence interval: 1.13-4.15). Subjects whose systolic blood pressure fell with hemodialysis had a significantly decreased risk of hospitalization or death at 6 months, suggesting that hemodynamic responses to dialysis are associated with short-term outcomes among a group of prevalent hemodialysis subjects. Further research should attempt to elucidate the mechanisms behind these findings. Significant controversy surrounds the issue of hypertension and outcomes among hemodialysis (HD) patients. Unlike the general population,1.Vasan R.S. Larson M.G. Leip E.P. et al.Impact of high-normal blood pressure on the risk of cardiovascular disease.N Engl J Med. 2001; 345: 1291-1297Crossref PubMed Scopus (1525) Google Scholar a direct association between elevated blood pressure (BP) and cardiovascular mortality has not been clearly identified in dialysis patients.2.Foley R.N. Herzog C.A. Collins A.J. Blood pressure and long-term mortality in US hemodialysis patients: USRDS Waves 3 and 4 Study.Kidney Int. 2002; 62: 1784-1790Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar, 3.Zager P.G. Nikolic J. Brown R.H. et al.U curve association of blood pressure and mortality in hemodialysis patients.Kidney Int. 1998; 54: 561-569Abstract Full Text Full Text PDF PubMed Scopus (560) Google Scholar, 4.Port F.K. Hulbert-Shearon T.E. Wolfe R.A. et al.Predialysis blood pressure and mortality risk in a national sample of maintenance hemodialysis patients.Am J Kidney Dis. 1999; 33: 507-517Abstract Full Text Full Text PDF PubMed Google Scholar, 5.Cheung A.K. Sarnak M.J. Yan G. et al.Cardiac diseases in maintenance hemodialysis patients: results of the HEMO study.Kidney Int. 2004; 65: 2380Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar, 6.Salem M.M. Bower J. Hypertension in the hemodialysis population: any relation to one-year survival?.Am J Kidney Dis. 1996; 28: 737-740Abstract Full Text PDF PubMed Scopus (82) Google Scholar, 7.Salem M.M. Hypertension in the haemodialysis population: any relationship to 2-years survival?.Nephrol Dial Transplant. 1999; 14: 125-128Crossref PubMed Scopus (74) Google Scholar, 8.Goodkin D.A. Bragg-Gresham J.L. Koenig K.G. et al.Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS).J Am Soc Nephrol. 2003; 14: 3270Crossref PubMed Scopus (594) Google Scholar, 9.Stidley C.A. Hunt W.C. Tentori F. et al.Changing relationship of blood pressure with mortality over time among hemodialysis patients.J Am Soc Nephrol. 2006; 17: 513-520Crossref PubMed Scopus (115) Google Scholar, 10.Klassen P.S. Lowrie E.G. Reddan D.N. et al.Association between pulse pressure and mortality in patients undergoing maintenance hemodialysis.JAMA. 2002; 287: 1548-1555Crossref PubMed Scopus (341) Google Scholar, 11.Agarwal R. Hypertension and survival in chronic hemodialysis patients – past lessons and future opportunities.Kidney Int. 2005; 67: 1-13Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar, 12.Foley R.N. Parfrey P.S. Harnett J.D. et al.Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease.Kidney Int. 1996; 49: 1379-1385Abstract Full Text PDF PubMed Scopus (410) Google Scholar Although long-term studies are required to define the association between hypertension and outcomes,11.Agarwal R. Hypertension and survival in chronic hemodialysis patients – past lessons and future opportunities.Kidney Int. 2005; 67: 1-13Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar pronounced mortality rates and the presence of comorbid conditions that contribute to high mortality among HD patients may limit the ability to detect an independent association between hypertension and outcomes. A number of studies have been published investigating the associations between BP and outcomes among end-stage renal disease (ESRD) patients.2.Foley R.N. Herzog C.A. Collins A.J. Blood pressure and long-term mortality in US hemodialysis patients: USRDS Waves 3 and 4 Study.Kidney Int. 2002; 62: 1784-1790Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar, 3.Zager P.G. Nikolic J. Brown R.H. et al.U curve association of blood pressure and mortality in hemodialysis patients.Kidney Int. 1998; 54: 561-569Abstract Full Text Full Text PDF PubMed Scopus (560) Google Scholar, 4.Port F.K. Hulbert-Shearon T.E. Wolfe R.A. et al.Predialysis blood pressure and mortality risk in a national sample of maintenance hemodialysis patients.Am J Kidney Dis. 1999; 33: 507-517Abstract Full Text Full Text PDF PubMed Google Scholar, 5.Cheung A.K. Sarnak M.J. Yan G. et al.Cardiac diseases in maintenance hemodialysis patients: results of the HEMO study.Kidney Int. 2004; 65: 2380Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar, 6.Salem M.M. Bower J. Hypertension in the hemodialysis population: any relation to one-year survival?.Am J Kidney Dis. 1996; 28: 737-740Abstract Full Text PDF PubMed Scopus (82) Google Scholar, 8.Goodkin D.A. Bragg-Gresham J.L. Koenig K.G. et al.Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS).J Am Soc Nephrol. 2003; 14: 3270Crossref PubMed Scopus (594) Google Scholar, 9.Stidley C.A. Hunt W.C. Tentori F. et al.Changing relationship of blood pressure with mortality over time among hemodialysis patients.J Am Soc Nephrol. 2006; 17: 513-520Crossref PubMed Scopus (115) Google Scholar, 10.Klassen P.S. Lowrie E.G. Reddan D.N. et al.Association between pulse pressure and mortality in patients undergoing maintenance hemodialysis.JAMA. 2002; 287: 1548-1555Crossref PubMed Scopus (341) Google Scholar, 11.Agarwal R. Hypertension and survival in chronic hemodialysis patients – past lessons and future opportunities.Kidney Int. 2005; 67: 1-13Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar, 12.Foley R.N. Parfrey P.S. Harnett J.D. et al.Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease.Kidney Int. 1996; 49: 1379-1385Abstract Full Text PDF PubMed Scopus (410) Google Scholar, 13.Fleischmann E.H. Bower J.D. Salahudeen A.K. Risk factor paradox in hemodialysis: better nutrition as a partial explanation.Asaio J. 2001; 47: 74-81Crossref PubMed Scopus (78) Google Scholar, 14.Kalantar-Zadeh K. Kilpatrick R.D. McAllister C.J. et al.Reverse epidemiology of hypertension and cardiovascular death in the hemodialysis population: the 58th annual fall conference and scientific sessions.Hypertension. 2005; 45: 811-817Crossref PubMed Scopus (178) Google Scholar The available observational studies suggest that the relationship between BP and outcomes is complex and differs from the general population. Unfortunately, there are a number of difficulties associated with studying the association between BP and outcomes among HD patients. First, it remains unclear which BP parameter to use in these studies: predialysis, postdialysis, and intradialytic changes in BP are all available, yet which parameter is most strongly associated with detrimental outcomes remains uncertain. Second, clinician's ability to change BP is limited in HD patients due to high frequency15.US Renal Data Systems USRDS 2004 annual data report: atlas of end-stage renal disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bdthesda, MD2004Google Scholar and severity16.Griffith T.F. Chua B.S. Allen A.S. et al.Characteristics of treated hypertension in incident hemodialysis and peritoneal dialysis patients.Am J Kidney Dis. 2003; 42: 1260-1269Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar of BP, as well as due to changes in BP associated with interdialytic weight gain, which is directly related to mortality risk.17.Szczech L.A. Reddan D.N. Klassen P.S. et al.Interactions between dialysis-related volume exposures, nutritional surrogates and mortality among ESRD patients.Nephrol Dial Transplant. 2003; 18: 1585-1591Crossref PubMed Scopus (45) Google Scholar, 18.Kimmel P.L. Varela M.P. Peterson R.A. et al.Interdialytic weight gain and survival in hemodialysis patients: effects of duration of ESRD and diabetes mellitus.Kidney Int. 2000; 57: 1141-1151Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar, 19.Lopez-Gomez J.M. Villaverde M. Jofre R. et al.Interdialytic weight gain as a marker of blood pressure, nutrition, and survival in hemodialysis patients.Kidney Int. 2005; : S63-S68Abstract Full Text Full Text PDF Scopus (99) Google Scholar Clinically, physicians are carefully balancing the relationship between intradialytic weight loss and BP. In some ESRD patients, BP is unaffected by ultrafiltration and hemodialysis, where as other patients experience a more pronounced hemodynamic response with hemodialysis. Differences in clinical characteristics between such patient groups have not been fully described nor has the relationship between BP responses to ultrafiltration with hemodialysis and outcomes been characterized to date.20.Sherman R.A. Daniel A. Cody R.P. The effect of interdialytic weight gain on predialysis blood pressure.Artif Organs. 1993; 17: 770-774Crossref PubMed Scopus (44) Google Scholar,21.Boon D. van Montfrans G.A. Koopman M.G. et al.Blood pressure response to uncomplicated hemodialysis: the importance of changes in stroke volume.Nephron Clin Pract. 2004; 96: c82-c87Crossref PubMed Scopus (41) Google Scholar Owing to the complex relationship between BP, weight gain, and mortality, we postulated that the association between hemodynamic changes and outcomes might be best assessed using other parameters such as hospitalization. Herein, we undertook a secondary analysis of CLIMB (the Crit-line Intradialytic Monitoring Benefit Study) to assess whether BP responses to hemodialysis are associated with differential short-term outcomes while controlling for interdialytic weight gain, case-mix, and other BP parameters. Baseline characteristics of subjects enrolled in the CLIMB study have been previously reported.22.Reddan D.N. Szczech L.A. Hasselblad V. et al.Intradialytic blood volume monitoring in ambulatory hemodialysis patients: a randomized trial.J Am Soc Nephrol. 2005; 16: 2162-2169Crossref PubMed Scopus (152) Google Scholar Two hundred and thirty subjects (52.5%) had a fall in systolic blood pressure (SBP) associated with HD (ΔSBP ≤-10 mm Hg), 150 subjects (34.2%) did not have a significant change in SBP from pre- to post-HD (ΔSBP -10 to 10 mm Hg), and 58 subjects (13.2%) exhibited a paradoxical rise in SBP with HD (ΔSBP ≥10 mm Hg) (Table 1). Subjects whose SBP fell with HD were younger and were on less antihypertensive medications. They also had higher predialysis systolic and diastolic BP, lower postdialysis systolic and diastolic BP, higher serum creatinine, and higher dry weights. There was a trend toward a higher prevalence of male subjects and a higher prevalence of diabetes mellitus among subjects whose SBP decreased during HD. Subjects whose SBP were unchanged with dialysis had the lowest prevalence of diabetes mellitus and the highest rates of catheter use compared to subjects whose SBP fell with HD or whose SBP rose with HD.Table 1Baseline clinical and demographic characteristics of the study populationSystolic blood pressure change (ΔSBP) associated with hemodialysisΔSBP ≤-10 mm Hg, n=230ΔSBP -10 to 10 mm Hg, n=150ΔSBP ≥10 mm Hg, n=58P-valueAge (years)57.36 (±14.97)60.34 (±16.00)63.64 (±16.54)0.013Gender (% male)55.2% (127/230)48.0% (72/150)43.1% (25/58)0.16Race (%) White55.2%66.0%55.2%0.14 Black38.3%28.7%38.9% Others6.5%5.3%6.9%Tobacco use (vs nonuse)27.9% (63/226)37.0% (54/146)28.1% (16/57)0.16Hispanic ethnicity (vs non-Hispanic)3.5% (8/230)1.3% (2/150)1.7% (1/58)0.37Diabetes mellitus (vs non-DM)49.1% (113/230)37.6% (56/149)46.4% (26/56)0.083Diabetes as cause of ESRD (vs others)33.9% (78/230)23.3% (35/150)36.2% (21/58)0.052Hypertension87.4% (201/230)92.6% (137/148)87.3% (48/55)0.24Antihypertensive medications (vs no antihypertensive use)73.9% (170/230)74.7% (112/150)87.9% (51/58)0.074Arrythmia17.2% (39/227)18.1% (27/149)20.7% (12/58)0.83Cardiac diseaseaCombined history of coronary disease or congestive heart disease.42.8% (98/229)35.3% (53/150)43.9% (25/57)0.30Chronic obstructive pulmonary disease10.0% (23/229)14.9% (22/148)16.1% (9/56)0.26Cerebrovascular disease20.0% (46/230)17.5% (26/149)14.3% (8/56)0.56Left ventricular hypertrophy29.1% (67/230)22.7% (34/150)24.1% (14/58)0.35Peripheral vascular disease20.5% (47/229)19.6% (29/148)17.9% (10/56)0.90Blood pressure (mm Hg) Predialysis Systolic155.46 (±18.40)144.51 (±22.45)139.28 (±21.62)<0.0001 Diastolic82.49 (±11.96)77.19 (±13.52)73.76 (±12.17)<0.0001Postdialysis Systolic130.52 (±17.26)142.43 (±21.88)157.92 (±20.53)<0.0001 Diastolic71.30 (±11.00)75.48 (±12.90)79.33 (±12.32)<0.0001 ΔSBP-24.94 (±12.69)-2.07 (±5.61)18.64 (±8.07)<0.0001Pulse pressure Predialysis72.97 (±15.07)67.32 (±15.09)65.53 (±17.29)0.0004 Postdialysis59.22 (±13.14)66.96 (±15.41)78.59 (±17.61)<0.0001% of interdialytic weight gain3.9% (±1.28)3.8% (±1.61)3.7% (±1.34)0.26Interdialytic weight gain (kg)3.11 kg (±1.07)2.70 (±1.08)2.62 (±1.11)0.0002Dry weight (kg)81.12 (±23.07)73.00 (±17.55)71.45 (±16.20)<0.0001Baseline laboratorybSeven subjects were missing baseline albumin, 36 missing creatinine, five missing calcium, five missing phosphorus, 217 missing PTH, 208 missing cholesterol, 59 subjects missing hemoglobin, and 44 missing URR. Albumin (g/dl)3.73 (±0.49)3.77 (±0.54)3.72 (±0.31)0.72 Creatinine (mg/dl)9.68 (±3.20)8.85 (±3.28)8.52 (±2.70)0.012 Calcium (mg/dl)9.27 (±0.96)9.14 (±0.89)8.96 (±0.82)0.053 Phosphorus (mg/dl)5.84 (±1.81)5.62 (±2.00)5.48 (±1.68)0.32 PTH, median (pg/ml)187.0 (64.0–435.0)193.0 (75.0–382.0)147.5 (53.3–214.5)0.44 Cholesterol (mg/dl)168.80 (±46.24)167.91 (±37.70)171.11 (±40.02)0.95 Hemoglobin (g/dl)11.42 (±1.43)11.52 (±1.33)11.11 (±1.35)0.18 URR, median0.72 (0.68–0.76)0.73 (0.68–0.78)0.75 (0.71–0.78)0.04 Number of antihypertensive medications (mean±s.d.)1.37 (±1.14)1.47 (±1.13)1.79 (±1.06)0.021Antihypertensive class (% use) Ace-I30.0% (69/230)28.7% (43/150)32.8% (19/58)0.85 Alpha-blocker4.4% (10/230)6.0% (9/150)3.5% (2/58)0.67 Beta-blocker35.2% (81/230)31.3% (47/150)39.7% (23/58)0.50 CCB35.2% (81/230)42.7% (64/150)44.8% (26/58)0.22 Diuretic3.5% (8/230)3.3% (5/150)6.9% (4/58)0.50 Nitrate11.0% (25/228)18.7% (28/150)24.2% (14/58)0.019 Vasodilator17.4% (40/230)16.7% (25/150)27.6% (16/58)0.18 Epoetin use (vs nonuse)89.6% (206/230)90.0% (135/150)87.9% (51/58)0.91Dialysis vintage 0–1 year26.6% (60/226)31.0% (45/145)25.9% (15/58)0.60 >1 year73.5% (166/226)69.0% (100/145)74.1% (43/58) Years (median±IQR)2.17 (0.97–4.02)1.68 (0.85–3.47)2.28 (0.96–4.03)0.25Access type AV fistula35.8% (82/229)32.9% (49/149)32.8% (19/58)0.023 AV graft44.5% (102/229)36.9% (55/149)55.2% (32/58) Catheter19.7% (45/229)30.2% (45/149)12.1% (7/58) Treatment Group (vs usual care)52.2% (120/230)43.3% (65/150)46.6% (27/58)0.23CCB, calcium channel blocker; AV, arteriovenous; URR, urea reduction ratio; PTH, parathyroid hormone.Note: to convert albumin in g/dl to g/l, multiply by 10; serum creatinine in mg/dl to mmol/l, multiply by 88.4; calcium in mg/dl to mmol/l, multiply by 0.2495; phosphorus in mg/dl to mmol/l, multiply by 0.3229; PTH in pg/ml to ng/l, multiply by 1; cholesterol in mg/dl to mmol/l, multiply by 0.02586; hemoglobin in g/dl to g/l, multiply by 10.a Combined history of coronary disease or congestive heart disease.b Seven subjects were missing baseline albumin, 36 missing creatinine, five missing calcium, five missing phosphorus, 217 missing PTH, 208 missing cholesterol, 59 subjects missing hemoglobin, and 44 missing URR. Open table in a new tab CCB, calcium channel blocker; AV, arteriovenous; URR, urea reduction ratio; PTH, parathyroid hormone. Note: to convert albumin in g/dl to g/l, multiply by 10; serum creatinine in mg/dl to mmol/l, multiply by 88.4; calcium in mg/dl to mmol/l, multiply by 0.2495; phosphorus in mg/dl to mmol/l, multiply by 0.3229; PTH in pg/ml to ng/l, multiply by 1; cholesterol in mg/dl to mmol/l, multiply by 0.02586; hemoglobin in g/dl to g/l, multiply by 10. During the 6-month follow-up, 132/438 (30.1%) subjects had a primary event (either non-access-related hospitalization (N=108) or death (N=5) or both (N=19)) (Table 2). Compared to subjects whose SBP fell with HD, subjects whose SBP was unchanged with HD or who had a paradoxical rise in SBP with HD had an increased risk of non-access-related hospitalization or death at 6 months (odds ratio (OR): 1.89, confidence interval (CI): 1.20–2.96, ΔSBP: -10 to 10 mm Hg vs ΔSBP ≤-10 mm Hg; OR: 2.14, CI: 1.17–3.93, ΔSBP ≥10 mm Hg vs ΔSBP ≤-10 mm Hg, P=0.0056). Annual non-access-related hospitalization rates were 0.96 (±2.96 hospitalizations/year) among subjects whose SBP fell with HD compared to 1.55 (±3.33) among subjects whose SBP was unchanged with HD and 1.90 (±3.86) among subjects whose SBP rose with HD (P=0.0083).Table 2Unadjusted comparison of 6-month mortality and non-access-related hospitalization rates among prevalent ESRD subjects grouped by changes in SBP with HDaReference is ΔSBP≤-10mm Hg.Number of subjects with an event (%)Odds ratio (95% CI)P-valueCombined end point of non-access-related hospitalization or death SBP fell with HD (ΔSBP ≤-10 mm Hg)54/230 (23.5%)1.00 (reference)0.0056 SBP unchanged with HD (ΔSBP -10 to 10 mm Hg)55/150 (36.7%)1.89 (1.20–2.96) SBP rose with HD (ΔSBP ≥10 mm Hg)23/58 (39.7%)2.14 (1.17–3.93)Non-access-related hospitalizationbFor this subgroup analysis alone, 19 subjects had both a hospitalization and death and were included in both analyses. SBP fell with HD (ΔSBP ≤-10 mm Hg)53/230 (23.0%)1.00 (reference)0.014 SBP unchanged with HD (ΔSBP -10 to 10 mm Hg)52/150 (34.7%)1.77 (1.12–2.79) SBP rose with HD (ΔSBP ≥10 mm Hg)22/58 (37.9%)2.04 (1.11–3.77)DeathbFor this subgroup analysis alone, 19 subjects had both a hospitalization and death and were included in both analyses. SBP fell with HD (ΔSBP ≤-10 mm Hg)7/230 (3.0%)1.00 (reference)0.046 SBP unchanged with HD (ΔSBP -10 to 10 mm Hg)11/150 (7.3%)2.52 (0.96–6.66) SBP rose with HD (ΔSBP ≥10 mm Hg)6/58 (10.3%)3.68 (1.19–11.40)Combined end point of non-access-related hospitalization or death ΔSBP (per 1 mm Hg increase)1.020 (1.01–1.03)0.0009a Reference is ΔSBP≤-10 mm Hg.b For this subgroup analysis alone, 19 subjects had both a hospitalization and death and were included in both analyses. Open table in a new tab When ΔSBP was modeled as a continuous variable, every 1 mm Hg increase in ΔSBP following HD was associated with an increased odds of a non-access-related hospitalization or death at 6 months (OR: 1.02, CI: 1.01–1.03, P=0.0009). Thus, a 10 mm Hg increase in SBP with HD was associated with a 20% increased odds of hospitalization or death at 6 months among subjects. The relationship between 10 mm Hg increments of ΔSBP and annual non-access-related hospitalization is plotted in Figure 1. After adjusting for relevant confounders, subjects whose SBP was unchanged with HD or whose SBP rose with HD had an increased risk of non-access-related hospitalization or death compared to patients whose SBP fell with HD (P=0.012) (Table 3).Table 3Adjusted analysis of 6-month mortality and non-access-related hospitalization among prevalent ESRD subjectsaVariables tested for significance included the following: age; race; dry weight; % of interdialytic weight gain; ΔSBP; dialysis vintage; access type; history of arrhythmia, cardiac disease (coronary artery disease or congestive heart disease), diabetes mellitus, hypertension, left ventricular hypertrophy, and peripheral vascular disease; baseline albumin, creatinine, calcium, phosphorus, and urea reduction ratio; number of BP medications; and treatment group.VariableOdds ratio (95% CI)P-valueSBP fell with HD (ΔSBP ≤-10 mm Hg)1.00 (reference)0.012SBP unchanged with HD (ΔSBP -10 to 10 mm Hg)1.85 (1.15–2.98)SBP rose with HD (ΔSBP ≥10 mm Hg)2.17 (1.13–4.15)Dry weight (per 1 kg increase)0.99 (0.97–1.00)0.018Cardiac disease (yes vs no)1.70 (1.10–2.64)0.018Treatment group (treatment vs usual care)1.62 (1.04–2.51)0.033Phosphorus (per 1 mg/dl increase)1.12 (1.001–1.26)0.049Black race (vs non-black race)0.65 (0.40–1.06)0.084a Variables tested for significance included the following: age; race; dry weight; % of interdialytic weight gain; ΔSBP; dialysis vintage; access type; history of arrhythmia, cardiac disease (coronary artery disease or congestive heart disease), diabetes mellitus, hypertension, left ventricular hypertrophy, and peripheral vascular disease; baseline albumin, creatinine, calcium, phosphorus, and urea reduction ratio; number of BP medications; and treatment group. Open table in a new tab In adjusted models with ΔSBP as a continuous variable, every 1 mm Hg increase in ΔSBP following HD was associated with a 2% increased odds of non-access-related hospitalization or death (OR: 1.02, CI: 1.01–1.03, P=0.0022). In multivariate analyses, other variables associated with an increased risk of hospitalization or death included lower dry weight (P=0.018), history of coronary artery disease or congestive heart disease (P=0.018), CLIMB treatment group (P=0.033), and increasing phosphorus (P=0.049). There was a trend toward improved outcomes among black subjects (P=0.084). Variables not associated with an increased risk of the primary outcome included increasing age; % of interdialytic weight gain; dialysis vintage; number of BP medications; access type; history of arrhythmia, diabetes mellitus, hypertension, left ventricular hypertrophy, or peripheral vascular disease; and baseline creatinine, albumin, calcium, or urea reduction ratio. ΔSBP category did not interact with age (P=0.76), race (P=0.92), % of interdialytic weight gain (P=0.55), history of coronary artery disease or congestive heart failure (P=0.25), diabetes mellitus (P=0.42), left ventricular hypertrophy (P=0.25), peripheral vascular disease (P=0.33), predialysis SBP (P=0.14), or predialysis diastolic BP (P=0.999). Four separate models were tested, which included the addition of predialysis systolic and diastolic BP, postdialysis systolic and diastolic BP, predialysis pulse pressure, and postdialysis pulse pressure. In each model performed, none of the BP parameters were associated with an increased risk of the primary outcome, nor did they significantly modify the effect of ΔSBP on outcomes (data not shown). Further sensitivity analyses were performed, which excluded subjects without KDOQI-(Kidney Disease Outcomes Quality Initiative) defined hypertension (predialysis SBP <140 and postdialysis SBP <130, and predialysis diastolic <90 and postdialysis diastolic <80). According to these standards, 343/431 (79%) subjects had hypertension in our cohort. After adjustment for relevant covariates, ΔSBP remained a strong predictor of outcomes among subjects with KDOQI-defined hypertension (Table 4).Table 4Combined outcome of 6-month mortality and non-access-related hospitalization among hypertensive (defined by KDOQI standards) ESRD subjects (N=343/431)Adjusted odds ratio (95% CI)aControlled for black race, cardiac disease, baseline phosphorus, dry weight, and treatment group.P-valueSBP fell with HD (ΔSBP ≤-10 mm Hg)1.00 (reference)0.006SBP unchanged with HD (ΔSBP -10 to 10 mm Hg)2.08 (1.19–3.61)SBP rose with HD (ΔSBP ≥10 mm Hg)2.61 (1.29–5.27)ΔSBP (per 1 mm Hg increase)1.02 (1.01–1.04)0.001a Controlled for black race, cardiac disease, baseline phosphorus, dry weight, and treatment group. Open table in a new tab Separate analyses included only subjects on antihypertensive medications to assess the impact of medication class on outcomes and to determine if specific antihypertensives modified the effect of ΔSBP on outcomes. In our cohort, 76% of subjects were on antihypertensive medications. None of the classes of antihypertensive agents were associated with the primary outcome (alpha blocker (P=0.88), angiotensin-converting enzyme-1 (P=0.30), β blocker (P=0.85), calcium channel blocker (P=0.99), diuretic (P=0.76), nitrate (P=0.31), or vasodilator (P=0.81)), nor did they modify the impact of ΔSBP on outcomes (data not shown). Our study demonstrates that hemodynamic responses with hemodialysis are associated with short-term clinical outcomes among a cohort of prevalent dialysis subjects. Although the effect of hypertension on long-term clinical outcomes remains uncertain,2.Foley R.N. Herzog C.A. Collins A.J. Blood pressure and long-term mortality in US hemodialysis patients: USRDS Waves 3 and 4 Study.Kidney Int. 2002; 62: 1784-1790Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar, 3.Zager P.G. Nikolic J. Brown R.H. et al.U curve association of blood pressure and mortality in hemodialysis patients.Kidney Int. 1998; 54: 561-569Abstract Full Text Full Text PDF PubMed Scopus (560) Google Scholar, 4.Port F.K. Hulbert-Shearon T.E. Wolfe R.A. et al.Predialysis blood pressure and mortality risk in a national sample of maintenance hemodialysis patients.Am J Kidney Dis. 1999; 33: 507-517Abstract Full Text Full Text PDF PubMed Google Scholar, 5.Cheung A.K. Sarnak M.J. Yan G. et al.Cardiac diseases in maintenance hemodialysis patients: results of the HEMO study.Kidney Int. 2004; 65: 2380Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar, 7.Salem M.M. Hypertension in the haemodialysis population: any relationship to 2-years survival?.Nephrol Dial Transplant. 1999; 14: 125-128Crossref PubMed Scopus (74) Google Scholar, 8.Goodkin D.A. Bragg-Gresham J.L. Koenig K.G. et al.Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS).J Am Soc Nephrol. 2003; 14: 3270Crossref PubMed Scopus (594) Google Scholar, 11.Agarwal R. Hypertension and survival in chronic hemodialysis patients – past lessons and future opportunities.Kidney Int. 2005; 67: 1-13Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar in our investigation, SBP that was unchanged with HD or paradoxically rose with HD was associated with an increased risk of non-access-related hospitalization or death at 6 months compared to SBP that fell with HD. Furthermore, in our investigation, BP changes associated with hemodialysis were more strongly associated with clinical outcomes than pre- or postdialysis systolic BP, diastolic BP, or pulse pressure. Our study suggests that hemodynamic responses to dialysis may be used to identify subject" @default.
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• W2068442384 title "Association of intradialytic blood pressure changes with hospitalization and mortality rates in prevalent ESRD patients" @default.
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