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The relationship between survival rate and intradialytic blood pressure changes in maintenance hemodialysis patients

The relationship between survival rate and intradialytic blood pressure changes in maintenance... RENAL FAILURE, 2017 VOL. 39, NO. 1, 417–422 http://dx.doi.org/10.1080/0886022X.2017.1305407 CLINICAL STUDY The relationship between survival rate and intradialytic blood pressure changes in maintenance hemodialysis patients a a a b b b b b Jiayue Lu , Minxia Zhu , Shang Liu , Mingli Zhu , Huihua Pang , Xinghui Lin , Zhaohui Ni , Jiaqi Qian , a,b a,b Hong Cai and Weiming Zhang Department of Nephrology, South Campus, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China ABSTRACT ARTICLE HISTORY Received 9 October 2016 Objective: The objective of this study is to investigate the relationship between blood pressure Revised 28 January 2017 changes and all-cause mortality, and between blood pressure changes and cardiovascular mortal- Accepted 6 March 2017 ity, for maintenance hemodialysis (MHD) patients during dialysis. Methods: Data regarding general condition, biochemical indices, and survival prognosis of MHD KEYWORDS patients who were treated at the Shanghai Jiao Tong University School of Medicine-affiliated Hemodialysis; blood Renji Hospital from July 2007 to December 2012 were collected, in order to evaluate the relation- pressure; hypertension; ship between patients’ blood pressure changes during hemodialysis and mortality. mortality Results: Among 364 patients, with an average age of 63.07 ± 13.93 years, an average dialysis vin- tage of 76.00 (range, 42.25–134.00) months, and a follow-up time of 54.86 ± 19.84 months, there were 85 cases (23.4%) of all-cause death and 46 cases (14.2%) of cardiovascular death. All-cause mortality and cardiovascular mortality were lowest (OR, 0.324 and 0.335; 95% CI, 0.152–0.692 and 0.123–0.911; p value, .004 and .032, respectively) in patients whose systolic blood pressure differ- ence (DSBP) before and after dialysis was between 7.09 and 14.25 mmHg. Kaplan–Meier analysis indicated that both all-cause mortality and cardiovascular mortality were markedly increased for patients with DSBPless than 0.25 mmHg (p value, .001 and .044, respectively). Cox regression analysis showed that DSBP<0.25 mmHg, hemoglobin concentration, Kt/v and albumin were independent risk factors for all-cause mortality in MHD patients. Conclusions: MHD patients whose blood pressure increased significantly after hemodialysis had a higher risk of dying; DSBP, hemoglobin concentration, Kt/v and albumin were independent risk factors for all-cause mortality in MHD patients. Mortality in maintenance hemodialysis (MHD) patients patients, SBP variability during treatment is independ- is high, especially cardiovascular mortality, which is ent of average SBP value, and that it is a strong pre- 3–10 times higher than in the general population. The dictor of stroke and transient ischemic attack (TIA), even increase in mortality is closely related to cardiovascular when antihypertensive drugs are used. It has been risk factors. These include changes in blood pressure reported by a few studies that SBP increase before (BP) such as a decrease or marked increase in systolic hemodialysis is an independent risk factor for all-cause 2 7 blood pressure (SBP) before hemodialysis, hypotension mortality in MHD patients. However, there is a lack of occurring during hemodialysis, changes in the structure data about the relationship between large differences of the heart such as left ventricular hypertrophy, extra- in blood pressure before and after hemodialysis and cellular overhydration, or neural hormone imbalance. long-term survival in MHD patients. In this study, a Studies have shown that, for the non-dialysis popula- retrospective analysis was conducted involving MHD patients who had been treated at our hospital, in order tion, blood pressure variability is a risk factor for cardio- to evaluate changes in blood pressure before and after vascular events, stroke, and left ventricular dialysis, and to investigate the relationship between hypertrophy. Similarly, blood pressure variability is one blood pressure variability during dialysis and all-cause of the most important cardiovascular risk factors for mortality, as well as cardiovascular mortality. MHD patients. There is some evidence that, for MHD CONTACT Hong Cai [email protected] Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Weiming Zhang [email protected] Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 418 J. LU ET AL. deviation, and the Bonferroni test was used for pairwise Subjects and methods comparisons among groups. Measurement data that Research subjects were not normally distributed were represented by Four hundred and two patients, who were registered in median and quartile, and the Mann–Whitney U test was the Shanghai Dialysis Registration System and have adopted for comparisons between groups. Comparisons received3 months of MHD treatment at the Shanghai between groups for quantitative data were conducted Jiao Tong University Medical School-affiliated Renji using the Chi-square test or the Fisher exact test. Cox Hospital from 1 July 2007 to 31 December 2012, were regression analysis was applied to analyze risk factors for selected. Thirty-eight of them were excluded due to all-cause mortality for MHD patients. Kaplan–Meier sur- incomplete registration data, and the remaining 364 vival curve was used to analyze the relationship between patients were included in the study. DSBP and survival rate in MHD patients. Patients’ demographic and clinical data were col- lected, including gender, age, height, dry weight, dialy- Results sis vintage, blood pressure before and after dialysis, Clinical manifestations and biochemical tests biomedical indices, etc. All patients were treated with bicarbonate dialysis fluid and F80 (Fresenius Co., Three hundred and sixty-four patients, 221 (60.7%) Homburg, Germany) or REXEED (Asahi Kasei Corp., male, with an average age of 63.07 ± 13.93 years and an Tokyo, Japan) polysulfone membrane dialyzer. The dia- average dialysis vintage of 76.00 (range, 42.25–134.00) lysis was conducted 2–3 times a week, lasting 4–5h months, were selected. There were 85 cases (23.4%) of each time (10–12 h/week) with 200–350 ml/min blood all-cause death and 46 cases (14.2%) of cardiovascular flow. Filtration volume was exceeded every time, in death (see Table 1 for patients’ demographic data and order to reach clinical dry weight. biochemical test results). Average SBP and DBP and MBP after dialysis were all higher in Group I compared with the other three Research methods groups; however, there was no statistically significant (1) Blood biochemical indices, including average values difference regarding average pre-dialysis SBP, DBP, SBP 2þ 3þ of corrected calcium (Ca ), phosphate (P ), intact CV, and post-dialysis SBP SD among the four groups parathyroid hormone (iPTH), total cholesterol (TC), tri- (see Table 2 for differences in blood pressure before glyceride (TG), low-density lipoprotein (LDL) cholesterol, and after dialysis). high-density lipoprotein (HDL), cholesterol, albumin (Alb), hemoglobin (Hb), and high-sensitivity C-reactive protein (hsCRP), were tested, and Kt/v were calculated The relationship between DSBP before and after for all patients. hemodialysis and risk of all-cause and (2) Blood pressure was recorded for all patients cardiovascular death before and after hemodialysis at first hemodialysis of every season. Average value, standard deviation, and Compared with patients in Group I variation coefficient of SBP and DBP, average arterial (DSBP<0.25 mmHg), the risk of all-cause death for pressure, DSBP[DSBP¼ SBP(before dialysis)SBP(after patients in Group II (0.25 mmHg DSBP <7.09 mmHg) dialysis)] and DMBP[DMBP¼ MAP(before dialysis)MAP and Group III (7.09 mmHg DSBP <14.25 mmHg) was (after dialysis)] were also calculated. significantly lower. After correcting for age, gender, dia- Patients were divided into four groups, based on lysis age, general individual conditions, and biochemical their relative DSBP level: Group I: first quartile indices, the difference was still statistically significant. (DSBP< P ); Group II: second quartile (P DSBP For patients in Group IV (DSBP 14.25 mmHg), the risk 25 25 of all-cause death decreased by 25.2% compared with < P ); Group III: third quartile (P DSBP< P ); and 50 50 75 Group I (DSBP<0.25 mmHg), but there was no statis- Group IV: fourth quartile (DSBP P ). General condi- tically significant difference between the two groups tions of patients in the four groups were compared (see Table 3). Among the patients who died of cardio- with each other. vascular diseases, the risk of cardiovascular death for patients in Group III (7.09 mmHg DSBP< 14.25 mmHg) Statistical methods was significantly lower than for those in Group I SPSS (version 20.0) software (SPSS Inc., Chicago, IL) was (DSBP<0.25 mmHg), and this difference remained used for statistical analysis. Normal distributed measure- statistically significant even after correcting for all ment data were represented by mean ± standard potential confounding factors (see Table 4). RENAL FAILURE 419 Table 1. Basic patient demographic characteristics and laboratory data, classified by quartiles of DSBP. Quartiles of DSBP (mmHg) All (n¼ 364) DSBP<0.25 0.25 DSBP< 7.09 7.09 DSBP< 14.25 DSBP 14.25 Number (n, %) 364 (100%) 92 (25.3) 90 (24.7) 91 (25.0) 91 (25.0) Male, n (%) 220 (60.6) 61 (27.7) 57 (63.3) 56 (61.5) 46 (51.1) Age (years) 63.07 ± 13.93 65.02 ± 13.72 62.47 ± 15.82 61.11 ± 11.95 63.50 ± 13.99 b b b Dialysis vintage, (month) 76.00 (42.25–134.00) 59.50 (32.0–96.5) 72.00 (50.75–124.5) 81.00 (46.0–144.0) 105.5 (48.75–144.25) b b b Follow up (month) 54.86 ± 19.84 48.99 ± 21.85 56.72 ± 18.14 57.89 ± 18.27 56.48 ± 19.40 2 b BMI (kg/m ) 22.06 ± 3.88 21.15 ± 4.05 21.77 ± 4.01 22.53 ± 3.55 22.83 ± 3.77 Kt/v 1.71 (1.50–1.99) 1.70 (1.48–2.03) 1.74 (1.49–1.91) 1.66 (1.47–1.95) 1.75 (1.58–2.03) Ca (mmol/l) 2.33 (2.21–2.46) 2.29 (2.17–2.39) 2.32 (2.19–2.41) 2.34 (2.23–2.48) 2.41 (2.24–2.56) P (mmol/l) 1.93 ± 0.40 1.87 ± 0.39 1.90 ± 0.40 1.97 ± 0.39 2.00 ± 0.42 b b b IPTH (pg/ml) 307.43 (157.20–536.09) 225.00 (141.10–376.00) 317.83 (137.32–539.34) 367.17 (153.00–630.86) 357.50 (235.56–585.12) hsCRP (mg/l) 17.13 (7.49–36.05) 14.37 (4.76–30.88) 16.34 (7.62–42.24) 20.23 (6.85–33.95) 20.33 (9.70–42.25) Alb (g/l) 39.35 ± 3.07 39.28 ± 3.42 39.36 ± 3.08 39.63 ± 2.73 39.28 ± 3.04 Hb (g/l) 107.89 ± 11.40 106.22 ± 12.21 107.83 ± 9.55 109.74 ± 12.66 107.90 ± 10.78 Triglycerides (mmol/l) 1.78 ± 0.86 1.79 ± 0.96 1.78 ± 0.79 1.78 ± 0.76 1.79 ± 0.94 Total cholesterol (mmol/l) 4.34 ± 0.76 4.31 ± 0.85 4.36 ± 0.69 4.32 ± 0.79 4.35 ± 0.82 Low-density lipoprotein (mmol/l) 2.35 ± 0.79 2.37 ± 0.67 2.34 ± 0.82 2.35 ± 0.68 2.36 ± 0.84 High-density lipoprotein (mmol/l) 1.17 ± 0.63 1.15 ± 0.59 1.19 ± 0.68 1.16 ± 0.58 1.18 ± 0.66 Anti-hypertensive ACEI/ARB (n, %) 196 (53.8) 46 (50.0) 52 (57.8) 50 (54.9) 48 (52.7) CCB (n, %) 165 (45.3) 44 (47.8) 38 (42.2) 41 (45.1) 42 (46.2) a,b-block (n, %) 72 (19.8) 18 (19.6) 16 (17.8) 21 (23.1) 17 (18.7) Mortality a b All cause (n, %) 84 (23.1) 33 (35.9) 16 (17.8) 13 (14.3) 22 (24.4) Cardiovascular (n, %) 46 (12.7) 17 (18.5) 11 (12.2) 6 (6.6) 12 (13.3) Compares with DSBP<0.25 group, p< .05. Compared with DSBP<0.25 group, p< .01. Table 2. Blood pressure changes before and after dialysis in maintenance hemodialysis patients. Quartiles of DSBP (mmHg) All (n¼ 364) DSBP<0.25 0.25 DSBP< 7.09 7.09 DSBP< 14.25 DSBP 14.25 Before Dialysis SBP SD (mmHg) 18.67 ± 7.4 19.52 ± 9.21 17.19 ± 6.07 18.51 ± 6.61 19.47 ± 7.2 Average SBP (mmHg) 142.49 ± 18.4 141.32 ± 19.22 139.48 ± 18.26 142.89 ± 15.95 146.09 ± 19.64 SBP CV 0.133 ± 0.054 0.139 ± 0.065 0.124 ± 0.440 0.131 ± 0.050 0.136 ± 0.054 DBP SD (mmHg) 10.19 ± 3.56 10.28 ± 4.03 9.84 ± 3.22 10.52 ± 3.70 10.16 ± 3.25 Average DBP (mmHg) 76.69 ± 10.65 76.46 ± 11.87 75.25 ± 10.99 77.52 ± 8.78 77.52 ± 10.77 DBP CV 0.136 ± 0.052 0.137 ± 0.059 0.134 ± 0.048 0.138 ± 0.054 0.133 ± 0.048 MBP (mmHg) 98.62 ± 12.00 98.08 ± 13.16 96.66 ± 12.13 99.31 ± 9.92 100.38 ± 12.48 After Dialysis SBP SD (mmHg) 19.79 ± 7.74 20.57 ± 9.47 18.77 ± 7.28 20.21 ± 7.00 19.18 ± 6.89 b b b Average SBP (mmHg) 135.09 ± 19.67 147.88 ± 19.23 136.16 ± 18.06 131.74 ± 16.14 124.34 ± 17.53 SBP CV 0.148 ± 0.056 0.140 ± 0.063 0.138 ± 0.051 0.154 ± 0.052 0.159 ± 0.055 DBP SD (mmHg) 10.69 ± 4.13 10.77 ± 4.86 9.82 ± 4.55 10.98 ± 3.33 11.16 ± 3.49 a b b Average DBP (mmHg) 74.84 ± 10.96 78.92 ± 11.71 75.79 ± 10.86 74.72 ± 9.03 69.84 ± 10.25 DBP CV 0.145 ± 0.057 0.138 ± 0.062 0.132 ± 0.062 0.150 ± 0.051 0.161 ± 0.050 b b b MBP (mmHg) 94.93 ± 12.79 101.91 ± 13.02 95.91 ± 12.16 93.73 ± 10.40 88.01 ± 11.56 Compares with DSBP<0.25 group, p< .05. Compared with DSBP<0.25 group, p< .01. Table 3. Association of DSBP and all-cause mortality. Quartiles of DSBP (mmHg) I DSBP<0.25 II 0.25 DSBP< 7.09 III 7.09 DSBP< 14.25 IV DSBP 14.25 n with death/total 33/92 16/90 13/91 22/91 unadjusted 1 0.387 (0.194–0.769) p¼ .007 0.298 (0.144–0.616) p¼ .001 0.578 (0.304–1.100) p¼ .095 Fully adjusted 1 0.421 (0.199–0.888) p¼ .023 0.324 (0.152–0.692) p¼ .004 0.748 (0.366–1.529) p¼ .426 Adjusted for age, sex, dialysis vintage, calcium, phosphorus, hemoglobin, hsCRP, Kt/v. Table 4. Association of DSBP and cardiovascular disease mortality. Quartiles of DSBP (mmHg) I DSBP<0.25 II 0.25 DSBP< 7.09 III 7.09 DSBP< 14.25 IV DSBP 14.25 n with death/total 17 (92) 11 (90) 6 (91) 12 (91) unadjusted 1 0.614 (0.270–1.397) p¼ .245 0.311 (0.117–0.831) p¼ .020 0.679 (0.304–1.517) p¼ .345 Fully adjusted 1 0.483 (0.190–1.228) p¼ .126 0.335 (0.123–0.911) p¼ .032 0.435 (0.160–1.181) p¼ .435 Adjusted for age, sex, dialysis vintage, calcium, phosphorus, hemoglobin, hsCRP, Kt/v. 420 J. LU ET AL. Analysis of risk factors for all-cause mortality in MHD patients The primary outcome of the study was death from any causes (all-cause mortality). COX regression analysis showed that the following factors were independently associated with all-cause mortality in MHD patients: DSBP>0.25 mmHg (OR¼ 0.472, 95%CI¼ 0.302–0.738, p¼ .001); hemoglobin concentration (OR¼ 0.575, 95%CI¼ 0.461–0.716, p< .001); and Kt/v (OR¼ 0.439, 95%CI¼ 0.260–0.739, p¼ .002); albumin (OR¼ 0.397, 95%CI¼ 0.242–0.650, p < .001). Relationship between DSBP and survival rate Kaplan–Meier analysis showed that, for patients with DSBP<0.25 mmHg, all-cause mortality and cardiovas- cular mortality were all significantly higher than for those in the other three groups (p¼ .001 and .044, Figure 1. Kaplan–Meier shows the relationship between DSBP respectively). Compared with patients in Group I and all-cause mortality. (DSBP<0.25 mmHg), the survival rate of cardiovascu- lar death for patients in Group II (0.25 mmHg DSBP <7.09 mmHg), Group III (7.09 mmHg DSBP <14.25 mmHg), and Group IV (DSBP 14.25 mmHg)was significantly higher (p¼ .003, p< .001, and p¼ .039, respectively). Among the patients who died of all-cause death, the survival rate was higher in Group III (7.09 mmHg< DSBP <14.25 mmHg) compared with Group I (DSBP<0.25 mmHg) (p¼ .005). The difference was no statistically significant among Group II, Group IV, and Group I (p¼ .109 and .171, respectively). This indicates that patients with higher SBP after hemodialy- sis had lower survival rate (see Figures 1 and 2). Discussion Blood pressure increase or decrease frequently occurs among patients during hemodialysis. Physicians usually pay attention to the development of hypotension and other complications occurring during hemodialysis, while the significance of blood pressure increase or Figure 2. Kaplan–Meier shows the relationship between DSBP moderate decrease during dialysis is easily overlooked. and cardiovascular disease mortality. In this study, 364 MHD patients were investigated, and the results showed that patients with found that increased SBP variability in MHD patients DSBP<0.25 mmHg during dialysis had higher mortal- before dialysis was an independent risk factor for all- ity, while those patients whose SBP moderately cause mortality. In our study, there was no statistical decreased had a higher survival rate. difference in average pre-dialysis SBP or coefficient of The increase in SBP during hemodialysis was closely SBP variation for patients whose SBP increased related to the increase in mortality, and SBP is increased >0.25 mmHg after dialysis, compared with the other in about 10–15% of patients after dialysis, according to three groups. In this study, the increased risk of all- some studies. Previous studies have also shown that cause mortality caused by an increase in SBP after dialy- SBP increase during hemodialysis is a sign of poor prog- sis was not affected by the average pre-dialysis SBP nosis in the short term. However, other studies have value and by SBP variability. RENAL FAILURE 421 Blood pressure after dialysis compared with blood blood pressure decrease after dialysis, the extent of pressure before dialysis can be used to estimate cardiac blood pressure decrease, and blood pressure increase stress during dialysis. In addition, the relationship after dialysis. Since the lowest blood pressure of between the increase in blood pressure during dialysis patients might be lower than the blood pressure meas- and poor outcomes reflects an increase in cyclic pres- ured immediately after dialysis, the blood pressure 11,12 sure loads. In the present study, hypertension value after dialysis may not accurately represent the related to dialysis might have been caused by excessive impact of the lowest blood pressure during dialysis on volume load, since many MHD patients did not reach patients’ survival. Moreover, blood pressure after dialy- their dry weight, and ultrafiltration of excessive fluid for sis might be influenced by multiple potential confound- patients during dialysis could have increased cardiac ers. In addition, the use of antihypertensive drugs was output, thereby increasing blood pressure, possibly not taken into account in this study, and the potential caused by an altered Frank–Starling curve. However, effects of various antihypertensive drugs on patient sur- other studies have indicated that endothelial dysfunc- vival were not studied. Furthermore, this study did not tion may be an important factor for the blood pressure consider the impact of residual renal function. increase occurring during dialysis. These studies have Residual renal function could be independently related found that, for patients whose blood pressure increased to mortality in MHD patients, since it contributes to the during dialysis, peripheral vascular resistance also relative stability of volume and could decrease weight fluctuations during dialysis. Moreover, the exact patho- increased after dialysis, which was not related to the physiology of blood pressure fluctuations during hemo- secretion of catecholamines and renin, but was related to endothelin-1 and nitric oxide. Some researchers have dialysis has not been identified in this study, and the suggested that blood pressure increase during dialysis impact of various factors (e.g. ultrafiltration method, may be related to endothelial cell dysfunction. temperature of dialysis fluid, etc.) on patients’ blood Endothelial cell injury is a sign of vascular injury, and it pressure fluctuations were unknown. Finally, this was a could increase the risk of death due to cardiovascular retrospective observational study. Patients were not 15–17 disease. In the present study, we found that, for randomized, and only those confounders were cor- patients whose blood pressure increase was rected for that had been recognized, detected, and >0.25 mmHg after dialysis, cardiovascular mortality was measured. also significantly increased, the mechanism of which To summarize, SBP changes before and after dialy- could involve endothelial cell dysfunction. sis in MHD patients were closely related to both all- Large decreases in SBP or DBP during hemodialysis cause and cardiovascular mortality. Patients with mod- can also increase mortality, while patients with moderate erate decreases of blood pressure after dialysis had a decreases have a higher survival rate, according to previ- higher survival rate, while patients whose blood pres- ous studies. Hypotension during dialysis is a common sure decreased less than 0.25 mmHg or increased complication, and patients whose SBP decreases during after dialysis compared with that before dialysis dem- dialysis and for whom orthostatic hypotension occurs onstrated significantly decreased rates of survival. after dialysis also demonstrate significantly decreased Consequently, blood pressure changes occurring dur- survival. For patients without coronary artery disease, a ing dialysis could be used as a treatment target to improve the prognosis for MHD patients. However, decrease in left ventricular function can be caused by the results of this study should be verified by pro- myocardial ischemia resulting from coronary blood flow spective, randomized, controlled studies involving a reduction or stressors on blood vessels during hemodi- large number of patients. alysis, etc. These factors together can cause irreversible 21,22 damage to the heart. Thus, a large decrease in blood pressure during hemodialysis may damage the cardio- Acknowledgements vascular system of patients, resulting in increased mortal- Clinical innovation and multi-discipline integrated medical ity. This study has found that patients with DSBP construction project of South Campus, Renji Hospital, School >14.25 mmHg did not have higher survival or lower car- of medicine, Shanghai Jiao Tong University (2014MDT02) and diovascular mortality compared with those with Scientific research startup foster fund of South Campus, Renji DSBP<0.25 mmHg, and there was no significant differ- Hospital, School of medicine, Shanghai Jiao Tong University ence in their survival rate, indicating that large decreases (2014qdq01). of SBP after dialysis did not benefit patients’ survival and may increase their risk of death. Disclosure statement However, this study has certain limitations. First of all, it analyzed the relationship between survival and None of the authors have any conflict of interest to declare. 422 J. LU ET AL. 11. Heerspink HJ, Ninomiya T, Zoungas S, et al. Effect of Funding lowering blood pressure on cardiovascular events and Scientific research startup foster fund of South Campus, Renji mortality in patients on dialysis: a systematic review Hospital, School of medicine, Shanghai Jiao Tong University and meta-analysis of randomised controlled trials. (2014qdq01). Lancet 2009;373:1009–1015. 12. Agarwal R, Sinha AD. Cardiovascular protection with antihypertensive drugs in dialysis patients. Systematic References review and meta-analysis. Hypertension 2009;53: 860–866. 1. Weiner DE, Tighiouart H, Amin MG, et al. Chronic kid- 13. Gunal AI, Karaca I, Celiker H, et al. Paradoxical rise in ney disease as a risk factor for cardiovascular disease blood pressure during ultrafiltration is caused by and all-cause mortality: A pooled analysis of commu- increased cardiac output. J Nephrol 2002;15:42–47. nity-based studies. J Am Soc Nephrol 2004;15: 14. Chou KJ, Lee PT, Chen CL, et al. Physiological changes 1307–1315. during hemodialysis in patients with intradialysis 2. Myers OB, Adams C, Rohrscheib MR, et al. Age, race, hypertension. Kidney Int 2006;69:1833–1838. diabetes, blood pressure, and mortality among hemo- 15. Koc M, Richards HB, Bihorac A, et al. Circulating dialysis patients. J Am Soc Nephrol 2010;21:1970–1878. endothelial cells are associated with future vascular 3. Paoletti E, Specchia C, Di Maio G, et al. The worsening events in hemodialysis patients. Kidney Int 2005;67: of left ventricular hypertrophy is the strongest pre- 1078–1083. dictor of sudden cardiac death in haemodialysis 16. Amabile N, Guerin AP, Leroyer A, et al. Circulating patients: A 10 year survey. Nephrol Dial Transplant endothelial microparticles are associated with vascular 2004;19:1829–1834. dysfunction in patients with end-stage renal failure. 4. Arkom N, Neil C, Edward S, et al. Increased postdialysis J Am Soc Nephrol 2005;16:3381–3388. systolic blood pressure is associated with extracellular 17. Werner N, Kosiol S, Schiegl T, et al. Circulating endo- overhydration in hemodialysis outpatients. Kidney Int thelial progenitor cells and cardiovascular outcomes. 2015;87:452–457. N Engl J Med 2005;353:999–1007. 5. Pringle E, Phillips C, Thijs L, et al. Systolic blood pres- 18. Park J, Rhee CM, Sim JJ, et al. A comparative effective- sure variability as a risk factor for stroke and cardiovas- ness research study of the change in blood pressure cular mortality in the elderly hypertensive population. during hemodialysis treatment and survival. Kidney Int J Hypertens 2003;21:2251–2257. 2013;84:795–802. 6. Rothwell PM, Howard SC, Dolan E, et al. Prognostic sig- 19. Shoji T, Tsubakihara Y, Fujii M, et al. Hemodialysis-asso- nificance of visit-to-visit variability, maximum systolic ciated hypotension as an independent risk factor for blood pressure, and episodic hypertension. Lancet two-year mortality in hemodialysis patients. Kidney Int 2010;375:895–905. 2004; 66:1212–1220. 7. Gu LJ, Zhang YR, Yuan WJ, et al. Related factors and 20. McIntyre CW, Burton JO, Selby NM, et al. prognostic of intradialytic blood pressure variability in Hemodialysis-induced cardiac dysfunction is associated patients on maintenance hemodialysis. Chin J Intern with an acute reduction in global and segmental Med 2013;52:453–458. myocardial blood flow. Clin J Am Soc Nephrol 2008;3: 8. Inrig JK. Intradialytic hypertension: A less-recognized 19–26. cardiovascular complication of hemodialysis. Am J 21. McIntyre CW. Recurrent circulatory stress: The dark side Kidney Dis 2010;55:580–589. of dialysis. Semin Dial 2010;23:449–451. 9. Inrig JK, Oddone EZ, Hasselblad V, et al. Association of 22. McIntyre CW. Effects of hemodialysis on cardiac func- intradialytic blood pressure changes with hospitaliza- tion. Kidney Int 2009;76:371–375. tion and mortality rates in prevalent ESRD patients. 23. Shafi T, Jaar BG, Plantinga LC, et al. Association of Kidney Int 2007;71:454–461. residual urine output with mortality, quality of life, and 10. Mendes RB, Santos SF, Dorigo D, et al. The use of peri- inflammation in incident hemodialysis patients: The dialysis blood pressure and intradialytic blood pressure Choices for Healthy Outcomes in Caring for End-Stage changes in the prediction of interdialytic blood pres- Renal Disease (CHOICE) Study. Am J Kidney Dis 2010; sure in haemodialysis patients. Blood Press Monit 2003;8:243–248. 56:348–358. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Renal Failure Taylor & Francis

The relationship between survival rate and intradialytic blood pressure changes in maintenance hemodialysis patients

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RENAL FAILURE, 2017 VOL. 39, NO. 1, 417–422 http://dx.doi.org/10.1080/0886022X.2017.1305407 CLINICAL STUDY The relationship between survival rate and intradialytic blood pressure changes in maintenance hemodialysis patients a a a b b b b b Jiayue Lu , Minxia Zhu , Shang Liu , Mingli Zhu , Huihua Pang , Xinghui Lin , Zhaohui Ni , Jiaqi Qian , a,b a,b Hong Cai and Weiming Zhang Department of Nephrology, South Campus, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China ABSTRACT ARTICLE HISTORY Received 9 October 2016 Objective: The objective of this study is to investigate the relationship between blood pressure Revised 28 January 2017 changes and all-cause mortality, and between blood pressure changes and cardiovascular mortal- Accepted 6 March 2017 ity, for maintenance hemodialysis (MHD) patients during dialysis. Methods: Data regarding general condition, biochemical indices, and survival prognosis of MHD KEYWORDS patients who were treated at the Shanghai Jiao Tong University School of Medicine-affiliated Hemodialysis; blood Renji Hospital from July 2007 to December 2012 were collected, in order to evaluate the relation- pressure; hypertension; ship between patients’ blood pressure changes during hemodialysis and mortality. mortality Results: Among 364 patients, with an average age of 63.07 ± 13.93 years, an average dialysis vin- tage of 76.00 (range, 42.25–134.00) months, and a follow-up time of 54.86 ± 19.84 months, there were 85 cases (23.4%) of all-cause death and 46 cases (14.2%) of cardiovascular death. All-cause mortality and cardiovascular mortality were lowest (OR, 0.324 and 0.335; 95% CI, 0.152–0.692 and 0.123–0.911; p value, .004 and .032, respectively) in patients whose systolic blood pressure differ- ence (DSBP) before and after dialysis was between 7.09 and 14.25 mmHg. Kaplan–Meier analysis indicated that both all-cause mortality and cardiovascular mortality were markedly increased for patients with DSBPless than 0.25 mmHg (p value, .001 and .044, respectively). Cox regression analysis showed that DSBP<0.25 mmHg, hemoglobin concentration, Kt/v and albumin were independent risk factors for all-cause mortality in MHD patients. Conclusions: MHD patients whose blood pressure increased significantly after hemodialysis had a higher risk of dying; DSBP, hemoglobin concentration, Kt/v and albumin were independent risk factors for all-cause mortality in MHD patients. Mortality in maintenance hemodialysis (MHD) patients patients, SBP variability during treatment is independ- is high, especially cardiovascular mortality, which is ent of average SBP value, and that it is a strong pre- 3–10 times higher than in the general population. The dictor of stroke and transient ischemic attack (TIA), even increase in mortality is closely related to cardiovascular when antihypertensive drugs are used. It has been risk factors. These include changes in blood pressure reported by a few studies that SBP increase before (BP) such as a decrease or marked increase in systolic hemodialysis is an independent risk factor for all-cause 2 7 blood pressure (SBP) before hemodialysis, hypotension mortality in MHD patients. However, there is a lack of occurring during hemodialysis, changes in the structure data about the relationship between large differences of the heart such as left ventricular hypertrophy, extra- in blood pressure before and after hemodialysis and cellular overhydration, or neural hormone imbalance. long-term survival in MHD patients. In this study, a Studies have shown that, for the non-dialysis popula- retrospective analysis was conducted involving MHD patients who had been treated at our hospital, in order tion, blood pressure variability is a risk factor for cardio- to evaluate changes in blood pressure before and after vascular events, stroke, and left ventricular dialysis, and to investigate the relationship between hypertrophy. Similarly, blood pressure variability is one blood pressure variability during dialysis and all-cause of the most important cardiovascular risk factors for mortality, as well as cardiovascular mortality. MHD patients. There is some evidence that, for MHD CONTACT Hong Cai [email protected] Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Weiming Zhang [email protected] Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 418 J. LU ET AL. deviation, and the Bonferroni test was used for pairwise Subjects and methods comparisons among groups. Measurement data that Research subjects were not normally distributed were represented by Four hundred and two patients, who were registered in median and quartile, and the Mann–Whitney U test was the Shanghai Dialysis Registration System and have adopted for comparisons between groups. Comparisons received3 months of MHD treatment at the Shanghai between groups for quantitative data were conducted Jiao Tong University Medical School-affiliated Renji using the Chi-square test or the Fisher exact test. Cox Hospital from 1 July 2007 to 31 December 2012, were regression analysis was applied to analyze risk factors for selected. Thirty-eight of them were excluded due to all-cause mortality for MHD patients. Kaplan–Meier sur- incomplete registration data, and the remaining 364 vival curve was used to analyze the relationship between patients were included in the study. DSBP and survival rate in MHD patients. Patients’ demographic and clinical data were col- lected, including gender, age, height, dry weight, dialy- Results sis vintage, blood pressure before and after dialysis, Clinical manifestations and biochemical tests biomedical indices, etc. All patients were treated with bicarbonate dialysis fluid and F80 (Fresenius Co., Three hundred and sixty-four patients, 221 (60.7%) Homburg, Germany) or REXEED (Asahi Kasei Corp., male, with an average age of 63.07 ± 13.93 years and an Tokyo, Japan) polysulfone membrane dialyzer. The dia- average dialysis vintage of 76.00 (range, 42.25–134.00) lysis was conducted 2–3 times a week, lasting 4–5h months, were selected. There were 85 cases (23.4%) of each time (10–12 h/week) with 200–350 ml/min blood all-cause death and 46 cases (14.2%) of cardiovascular flow. Filtration volume was exceeded every time, in death (see Table 1 for patients’ demographic data and order to reach clinical dry weight. biochemical test results). Average SBP and DBP and MBP after dialysis were all higher in Group I compared with the other three Research methods groups; however, there was no statistically significant (1) Blood biochemical indices, including average values difference regarding average pre-dialysis SBP, DBP, SBP 2þ 3þ of corrected calcium (Ca ), phosphate (P ), intact CV, and post-dialysis SBP SD among the four groups parathyroid hormone (iPTH), total cholesterol (TC), tri- (see Table 2 for differences in blood pressure before glyceride (TG), low-density lipoprotein (LDL) cholesterol, and after dialysis). high-density lipoprotein (HDL), cholesterol, albumin (Alb), hemoglobin (Hb), and high-sensitivity C-reactive protein (hsCRP), were tested, and Kt/v were calculated The relationship between DSBP before and after for all patients. hemodialysis and risk of all-cause and (2) Blood pressure was recorded for all patients cardiovascular death before and after hemodialysis at first hemodialysis of every season. Average value, standard deviation, and Compared with patients in Group I variation coefficient of SBP and DBP, average arterial (DSBP<0.25 mmHg), the risk of all-cause death for pressure, DSBP[DSBP¼ SBP(before dialysis)SBP(after patients in Group II (0.25 mmHg DSBP <7.09 mmHg) dialysis)] and DMBP[DMBP¼ MAP(before dialysis)MAP and Group III (7.09 mmHg DSBP <14.25 mmHg) was (after dialysis)] were also calculated. significantly lower. After correcting for age, gender, dia- Patients were divided into four groups, based on lysis age, general individual conditions, and biochemical their relative DSBP level: Group I: first quartile indices, the difference was still statistically significant. (DSBP< P ); Group II: second quartile (P DSBP For patients in Group IV (DSBP 14.25 mmHg), the risk 25 25 of all-cause death decreased by 25.2% compared with < P ); Group III: third quartile (P DSBP< P ); and 50 50 75 Group I (DSBP<0.25 mmHg), but there was no statis- Group IV: fourth quartile (DSBP P ). General condi- tically significant difference between the two groups tions of patients in the four groups were compared (see Table 3). Among the patients who died of cardio- with each other. vascular diseases, the risk of cardiovascular death for patients in Group III (7.09 mmHg DSBP< 14.25 mmHg) Statistical methods was significantly lower than for those in Group I SPSS (version 20.0) software (SPSS Inc., Chicago, IL) was (DSBP<0.25 mmHg), and this difference remained used for statistical analysis. Normal distributed measure- statistically significant even after correcting for all ment data were represented by mean ± standard potential confounding factors (see Table 4). RENAL FAILURE 419 Table 1. Basic patient demographic characteristics and laboratory data, classified by quartiles of DSBP. Quartiles of DSBP (mmHg) All (n¼ 364) DSBP<0.25 0.25 DSBP< 7.09 7.09 DSBP< 14.25 DSBP 14.25 Number (n, %) 364 (100%) 92 (25.3) 90 (24.7) 91 (25.0) 91 (25.0) Male, n (%) 220 (60.6) 61 (27.7) 57 (63.3) 56 (61.5) 46 (51.1) Age (years) 63.07 ± 13.93 65.02 ± 13.72 62.47 ± 15.82 61.11 ± 11.95 63.50 ± 13.99 b b b Dialysis vintage, (month) 76.00 (42.25–134.00) 59.50 (32.0–96.5) 72.00 (50.75–124.5) 81.00 (46.0–144.0) 105.5 (48.75–144.25) b b b Follow up (month) 54.86 ± 19.84 48.99 ± 21.85 56.72 ± 18.14 57.89 ± 18.27 56.48 ± 19.40 2 b BMI (kg/m ) 22.06 ± 3.88 21.15 ± 4.05 21.77 ± 4.01 22.53 ± 3.55 22.83 ± 3.77 Kt/v 1.71 (1.50–1.99) 1.70 (1.48–2.03) 1.74 (1.49–1.91) 1.66 (1.47–1.95) 1.75 (1.58–2.03) Ca (mmol/l) 2.33 (2.21–2.46) 2.29 (2.17–2.39) 2.32 (2.19–2.41) 2.34 (2.23–2.48) 2.41 (2.24–2.56) P (mmol/l) 1.93 ± 0.40 1.87 ± 0.39 1.90 ± 0.40 1.97 ± 0.39 2.00 ± 0.42 b b b IPTH (pg/ml) 307.43 (157.20–536.09) 225.00 (141.10–376.00) 317.83 (137.32–539.34) 367.17 (153.00–630.86) 357.50 (235.56–585.12) hsCRP (mg/l) 17.13 (7.49–36.05) 14.37 (4.76–30.88) 16.34 (7.62–42.24) 20.23 (6.85–33.95) 20.33 (9.70–42.25) Alb (g/l) 39.35 ± 3.07 39.28 ± 3.42 39.36 ± 3.08 39.63 ± 2.73 39.28 ± 3.04 Hb (g/l) 107.89 ± 11.40 106.22 ± 12.21 107.83 ± 9.55 109.74 ± 12.66 107.90 ± 10.78 Triglycerides (mmol/l) 1.78 ± 0.86 1.79 ± 0.96 1.78 ± 0.79 1.78 ± 0.76 1.79 ± 0.94 Total cholesterol (mmol/l) 4.34 ± 0.76 4.31 ± 0.85 4.36 ± 0.69 4.32 ± 0.79 4.35 ± 0.82 Low-density lipoprotein (mmol/l) 2.35 ± 0.79 2.37 ± 0.67 2.34 ± 0.82 2.35 ± 0.68 2.36 ± 0.84 High-density lipoprotein (mmol/l) 1.17 ± 0.63 1.15 ± 0.59 1.19 ± 0.68 1.16 ± 0.58 1.18 ± 0.66 Anti-hypertensive ACEI/ARB (n, %) 196 (53.8) 46 (50.0) 52 (57.8) 50 (54.9) 48 (52.7) CCB (n, %) 165 (45.3) 44 (47.8) 38 (42.2) 41 (45.1) 42 (46.2) a,b-block (n, %) 72 (19.8) 18 (19.6) 16 (17.8) 21 (23.1) 17 (18.7) Mortality a b All cause (n, %) 84 (23.1) 33 (35.9) 16 (17.8) 13 (14.3) 22 (24.4) Cardiovascular (n, %) 46 (12.7) 17 (18.5) 11 (12.2) 6 (6.6) 12 (13.3) Compares with DSBP<0.25 group, p< .05. Compared with DSBP<0.25 group, p< .01. Table 2. Blood pressure changes before and after dialysis in maintenance hemodialysis patients. Quartiles of DSBP (mmHg) All (n¼ 364) DSBP<0.25 0.25 DSBP< 7.09 7.09 DSBP< 14.25 DSBP 14.25 Before Dialysis SBP SD (mmHg) 18.67 ± 7.4 19.52 ± 9.21 17.19 ± 6.07 18.51 ± 6.61 19.47 ± 7.2 Average SBP (mmHg) 142.49 ± 18.4 141.32 ± 19.22 139.48 ± 18.26 142.89 ± 15.95 146.09 ± 19.64 SBP CV 0.133 ± 0.054 0.139 ± 0.065 0.124 ± 0.440 0.131 ± 0.050 0.136 ± 0.054 DBP SD (mmHg) 10.19 ± 3.56 10.28 ± 4.03 9.84 ± 3.22 10.52 ± 3.70 10.16 ± 3.25 Average DBP (mmHg) 76.69 ± 10.65 76.46 ± 11.87 75.25 ± 10.99 77.52 ± 8.78 77.52 ± 10.77 DBP CV 0.136 ± 0.052 0.137 ± 0.059 0.134 ± 0.048 0.138 ± 0.054 0.133 ± 0.048 MBP (mmHg) 98.62 ± 12.00 98.08 ± 13.16 96.66 ± 12.13 99.31 ± 9.92 100.38 ± 12.48 After Dialysis SBP SD (mmHg) 19.79 ± 7.74 20.57 ± 9.47 18.77 ± 7.28 20.21 ± 7.00 19.18 ± 6.89 b b b Average SBP (mmHg) 135.09 ± 19.67 147.88 ± 19.23 136.16 ± 18.06 131.74 ± 16.14 124.34 ± 17.53 SBP CV 0.148 ± 0.056 0.140 ± 0.063 0.138 ± 0.051 0.154 ± 0.052 0.159 ± 0.055 DBP SD (mmHg) 10.69 ± 4.13 10.77 ± 4.86 9.82 ± 4.55 10.98 ± 3.33 11.16 ± 3.49 a b b Average DBP (mmHg) 74.84 ± 10.96 78.92 ± 11.71 75.79 ± 10.86 74.72 ± 9.03 69.84 ± 10.25 DBP CV 0.145 ± 0.057 0.138 ± 0.062 0.132 ± 0.062 0.150 ± 0.051 0.161 ± 0.050 b b b MBP (mmHg) 94.93 ± 12.79 101.91 ± 13.02 95.91 ± 12.16 93.73 ± 10.40 88.01 ± 11.56 Compares with DSBP<0.25 group, p< .05. Compared with DSBP<0.25 group, p< .01. Table 3. Association of DSBP and all-cause mortality. Quartiles of DSBP (mmHg) I DSBP<0.25 II 0.25 DSBP< 7.09 III 7.09 DSBP< 14.25 IV DSBP 14.25 n with death/total 33/92 16/90 13/91 22/91 unadjusted 1 0.387 (0.194–0.769) p¼ .007 0.298 (0.144–0.616) p¼ .001 0.578 (0.304–1.100) p¼ .095 Fully adjusted 1 0.421 (0.199–0.888) p¼ .023 0.324 (0.152–0.692) p¼ .004 0.748 (0.366–1.529) p¼ .426 Adjusted for age, sex, dialysis vintage, calcium, phosphorus, hemoglobin, hsCRP, Kt/v. Table 4. Association of DSBP and cardiovascular disease mortality. Quartiles of DSBP (mmHg) I DSBP<0.25 II 0.25 DSBP< 7.09 III 7.09 DSBP< 14.25 IV DSBP 14.25 n with death/total 17 (92) 11 (90) 6 (91) 12 (91) unadjusted 1 0.614 (0.270–1.397) p¼ .245 0.311 (0.117–0.831) p¼ .020 0.679 (0.304–1.517) p¼ .345 Fully adjusted 1 0.483 (0.190–1.228) p¼ .126 0.335 (0.123–0.911) p¼ .032 0.435 (0.160–1.181) p¼ .435 Adjusted for age, sex, dialysis vintage, calcium, phosphorus, hemoglobin, hsCRP, Kt/v. 420 J. LU ET AL. Analysis of risk factors for all-cause mortality in MHD patients The primary outcome of the study was death from any causes (all-cause mortality). COX regression analysis showed that the following factors were independently associated with all-cause mortality in MHD patients: DSBP>0.25 mmHg (OR¼ 0.472, 95%CI¼ 0.302–0.738, p¼ .001); hemoglobin concentration (OR¼ 0.575, 95%CI¼ 0.461–0.716, p< .001); and Kt/v (OR¼ 0.439, 95%CI¼ 0.260–0.739, p¼ .002); albumin (OR¼ 0.397, 95%CI¼ 0.242–0.650, p < .001). Relationship between DSBP and survival rate Kaplan–Meier analysis showed that, for patients with DSBP<0.25 mmHg, all-cause mortality and cardiovas- cular mortality were all significantly higher than for those in the other three groups (p¼ .001 and .044, Figure 1. Kaplan–Meier shows the relationship between DSBP respectively). Compared with patients in Group I and all-cause mortality. (DSBP<0.25 mmHg), the survival rate of cardiovascu- lar death for patients in Group II (0.25 mmHg DSBP <7.09 mmHg), Group III (7.09 mmHg DSBP <14.25 mmHg), and Group IV (DSBP 14.25 mmHg)was significantly higher (p¼ .003, p< .001, and p¼ .039, respectively). Among the patients who died of all-cause death, the survival rate was higher in Group III (7.09 mmHg< DSBP <14.25 mmHg) compared with Group I (DSBP<0.25 mmHg) (p¼ .005). The difference was no statistically significant among Group II, Group IV, and Group I (p¼ .109 and .171, respectively). This indicates that patients with higher SBP after hemodialy- sis had lower survival rate (see Figures 1 and 2). Discussion Blood pressure increase or decrease frequently occurs among patients during hemodialysis. Physicians usually pay attention to the development of hypotension and other complications occurring during hemodialysis, while the significance of blood pressure increase or Figure 2. Kaplan–Meier shows the relationship between DSBP moderate decrease during dialysis is easily overlooked. and cardiovascular disease mortality. In this study, 364 MHD patients were investigated, and the results showed that patients with found that increased SBP variability in MHD patients DSBP<0.25 mmHg during dialysis had higher mortal- before dialysis was an independent risk factor for all- ity, while those patients whose SBP moderately cause mortality. In our study, there was no statistical decreased had a higher survival rate. difference in average pre-dialysis SBP or coefficient of The increase in SBP during hemodialysis was closely SBP variation for patients whose SBP increased related to the increase in mortality, and SBP is increased >0.25 mmHg after dialysis, compared with the other in about 10–15% of patients after dialysis, according to three groups. In this study, the increased risk of all- some studies. Previous studies have also shown that cause mortality caused by an increase in SBP after dialy- SBP increase during hemodialysis is a sign of poor prog- sis was not affected by the average pre-dialysis SBP nosis in the short term. However, other studies have value and by SBP variability. RENAL FAILURE 421 Blood pressure after dialysis compared with blood blood pressure decrease after dialysis, the extent of pressure before dialysis can be used to estimate cardiac blood pressure decrease, and blood pressure increase stress during dialysis. In addition, the relationship after dialysis. Since the lowest blood pressure of between the increase in blood pressure during dialysis patients might be lower than the blood pressure meas- and poor outcomes reflects an increase in cyclic pres- ured immediately after dialysis, the blood pressure 11,12 sure loads. In the present study, hypertension value after dialysis may not accurately represent the related to dialysis might have been caused by excessive impact of the lowest blood pressure during dialysis on volume load, since many MHD patients did not reach patients’ survival. Moreover, blood pressure after dialy- their dry weight, and ultrafiltration of excessive fluid for sis might be influenced by multiple potential confound- patients during dialysis could have increased cardiac ers. In addition, the use of antihypertensive drugs was output, thereby increasing blood pressure, possibly not taken into account in this study, and the potential caused by an altered Frank–Starling curve. However, effects of various antihypertensive drugs on patient sur- other studies have indicated that endothelial dysfunc- vival were not studied. Furthermore, this study did not tion may be an important factor for the blood pressure consider the impact of residual renal function. increase occurring during dialysis. These studies have Residual renal function could be independently related found that, for patients whose blood pressure increased to mortality in MHD patients, since it contributes to the during dialysis, peripheral vascular resistance also relative stability of volume and could decrease weight fluctuations during dialysis. Moreover, the exact patho- increased after dialysis, which was not related to the physiology of blood pressure fluctuations during hemo- secretion of catecholamines and renin, but was related to endothelin-1 and nitric oxide. Some researchers have dialysis has not been identified in this study, and the suggested that blood pressure increase during dialysis impact of various factors (e.g. ultrafiltration method, may be related to endothelial cell dysfunction. temperature of dialysis fluid, etc.) on patients’ blood Endothelial cell injury is a sign of vascular injury, and it pressure fluctuations were unknown. Finally, this was a could increase the risk of death due to cardiovascular retrospective observational study. Patients were not 15–17 disease. In the present study, we found that, for randomized, and only those confounders were cor- patients whose blood pressure increase was rected for that had been recognized, detected, and >0.25 mmHg after dialysis, cardiovascular mortality was measured. also significantly increased, the mechanism of which To summarize, SBP changes before and after dialy- could involve endothelial cell dysfunction. sis in MHD patients were closely related to both all- Large decreases in SBP or DBP during hemodialysis cause and cardiovascular mortality. Patients with mod- can also increase mortality, while patients with moderate erate decreases of blood pressure after dialysis had a decreases have a higher survival rate, according to previ- higher survival rate, while patients whose blood pres- ous studies. Hypotension during dialysis is a common sure decreased less than 0.25 mmHg or increased complication, and patients whose SBP decreases during after dialysis compared with that before dialysis dem- dialysis and for whom orthostatic hypotension occurs onstrated significantly decreased rates of survival. after dialysis also demonstrate significantly decreased Consequently, blood pressure changes occurring dur- survival. For patients without coronary artery disease, a ing dialysis could be used as a treatment target to improve the prognosis for MHD patients. However, decrease in left ventricular function can be caused by the results of this study should be verified by pro- myocardial ischemia resulting from coronary blood flow spective, randomized, controlled studies involving a reduction or stressors on blood vessels during hemodi- large number of patients. alysis, etc. These factors together can cause irreversible 21,22 damage to the heart. Thus, a large decrease in blood pressure during hemodialysis may damage the cardio- Acknowledgements vascular system of patients, resulting in increased mortal- Clinical innovation and multi-discipline integrated medical ity. This study has found that patients with DSBP construction project of South Campus, Renji Hospital, School >14.25 mmHg did not have higher survival or lower car- of medicine, Shanghai Jiao Tong University (2014MDT02) and diovascular mortality compared with those with Scientific research startup foster fund of South Campus, Renji DSBP<0.25 mmHg, and there was no significant differ- Hospital, School of medicine, Shanghai Jiao Tong University ence in their survival rate, indicating that large decreases (2014qdq01). of SBP after dialysis did not benefit patients’ survival and may increase their risk of death. Disclosure statement However, this study has certain limitations. First of all, it analyzed the relationship between survival and None of the authors have any conflict of interest to declare. 422 J. LU ET AL. 11. Heerspink HJ, Ninomiya T, Zoungas S, et al. Effect of Funding lowering blood pressure on cardiovascular events and Scientific research startup foster fund of South Campus, Renji mortality in patients on dialysis: a systematic review Hospital, School of medicine, Shanghai Jiao Tong University and meta-analysis of randomised controlled trials. (2014qdq01). Lancet 2009;373:1009–1015. 12. Agarwal R, Sinha AD. Cardiovascular protection with antihypertensive drugs in dialysis patients. Systematic References review and meta-analysis. Hypertension 2009;53: 860–866. 1. Weiner DE, Tighiouart H, Amin MG, et al. Chronic kid- 13. Gunal AI, Karaca I, Celiker H, et al. Paradoxical rise in ney disease as a risk factor for cardiovascular disease blood pressure during ultrafiltration is caused by and all-cause mortality: A pooled analysis of commu- increased cardiac output. J Nephrol 2002;15:42–47. nity-based studies. J Am Soc Nephrol 2004;15: 14. Chou KJ, Lee PT, Chen CL, et al. Physiological changes 1307–1315. during hemodialysis in patients with intradialysis 2. Myers OB, Adams C, Rohrscheib MR, et al. Age, race, hypertension. Kidney Int 2006;69:1833–1838. diabetes, blood pressure, and mortality among hemo- 15. Koc M, Richards HB, Bihorac A, et al. Circulating dialysis patients. J Am Soc Nephrol 2010;21:1970–1878. endothelial cells are associated with future vascular 3. Paoletti E, Specchia C, Di Maio G, et al. The worsening events in hemodialysis patients. Kidney Int 2005;67: of left ventricular hypertrophy is the strongest pre- 1078–1083. dictor of sudden cardiac death in haemodialysis 16. Amabile N, Guerin AP, Leroyer A, et al. Circulating patients: A 10 year survey. Nephrol Dial Transplant endothelial microparticles are associated with vascular 2004;19:1829–1834. dysfunction in patients with end-stage renal failure. 4. Arkom N, Neil C, Edward S, et al. Increased postdialysis J Am Soc Nephrol 2005;16:3381–3388. systolic blood pressure is associated with extracellular 17. Werner N, Kosiol S, Schiegl T, et al. Circulating endo- overhydration in hemodialysis outpatients. Kidney Int thelial progenitor cells and cardiovascular outcomes. 2015;87:452–457. N Engl J Med 2005;353:999–1007. 5. Pringle E, Phillips C, Thijs L, et al. Systolic blood pres- 18. Park J, Rhee CM, Sim JJ, et al. A comparative effective- sure variability as a risk factor for stroke and cardiovas- ness research study of the change in blood pressure cular mortality in the elderly hypertensive population. during hemodialysis treatment and survival. Kidney Int J Hypertens 2003;21:2251–2257. 2013;84:795–802. 6. Rothwell PM, Howard SC, Dolan E, et al. Prognostic sig- 19. Shoji T, Tsubakihara Y, Fujii M, et al. Hemodialysis-asso- nificance of visit-to-visit variability, maximum systolic ciated hypotension as an independent risk factor for blood pressure, and episodic hypertension. Lancet two-year mortality in hemodialysis patients. Kidney Int 2010;375:895–905. 2004; 66:1212–1220. 7. Gu LJ, Zhang YR, Yuan WJ, et al. Related factors and 20. McIntyre CW, Burton JO, Selby NM, et al. prognostic of intradialytic blood pressure variability in Hemodialysis-induced cardiac dysfunction is associated patients on maintenance hemodialysis. Chin J Intern with an acute reduction in global and segmental Med 2013;52:453–458. myocardial blood flow. Clin J Am Soc Nephrol 2008;3: 8. Inrig JK. Intradialytic hypertension: A less-recognized 19–26. cardiovascular complication of hemodialysis. Am J 21. McIntyre CW. Recurrent circulatory stress: The dark side Kidney Dis 2010;55:580–589. of dialysis. Semin Dial 2010;23:449–451. 9. Inrig JK, Oddone EZ, Hasselblad V, et al. Association of 22. McIntyre CW. Effects of hemodialysis on cardiac func- intradialytic blood pressure changes with hospitaliza- tion. Kidney Int 2009;76:371–375. tion and mortality rates in prevalent ESRD patients. 23. Shafi T, Jaar BG, Plantinga LC, et al. Association of Kidney Int 2007;71:454–461. residual urine output with mortality, quality of life, and 10. Mendes RB, Santos SF, Dorigo D, et al. The use of peri- inflammation in incident hemodialysis patients: The dialysis blood pressure and intradialytic blood pressure Choices for Healthy Outcomes in Caring for End-Stage changes in the prediction of interdialytic blood pres- Renal Disease (CHOICE) Study. Am J Kidney Dis 2010; sure in haemodialysis patients. Blood Press Monit 2003;8:243–248. 56:348–358.

Journal

Renal Failure – Taylor & Francis

Published: Jan 1, 2017

Keywords: Hemodialysis; blood pressure; hypertension; mortality

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