Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality

Keiichi Sumida, Miklos Z. Molnar, Praveen K. Potukuchi, Fridtjof Thomas, Jun Ling Lu, Vanessa A. Ravel, Melissa Soohoo, Connie M. Rhee, Elani Streja, John J. Sim, Kunihiro Yamagata, Kamyar Kalantar-Zadeh, Csaba P. Kovesdy

Research output: Contribution to journalArticle

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Abstract

Background Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown. Study Design Observational study. Setting & Participants 17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years. Predictor Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to ≥160 mm Hg in 10−mm Hg increments) and 5 (<60 to ≥90 mm Hg in 10−mm Hg increments) categories, respectively, and as continuous measures. Outcomes & Measurements Postdialysis all-cause mortality, assessed over different follow-up periods (ie, <3, 3-<6, 6-<12, and ≥12 months after dialysis therapy initiation) using Cox regressions adjusted for demographics, comorbid conditions, medications, cardiovascular medication adherence, body mass index, estimated glomerular filtration rate, and type of vascular access. Results Mean predialysis SBP and DBP were 141.2 ± 16.1 (SD) and 73.7 ± 10.6 mm Hg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP < 140 mm Hg. Mortality risks associated with lower SBP were greatest in the first 3 months after dialysis therapy initiation, with multivariable-adjusted HRs of 2.40 (95% CI, 1.96-2.93), 1.99 (95% CI, 1.66-2.40), 1.35 (95% CI, 1.13-1.62), 0.98 (95% CI, 0.78-1.22), and 0.76 (95% CI, 0.57-1.00) for SBP <120, 120 to <130, 130 to <140, 150 to <160, and ≥160 (vs 140-<150) mm Hg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality. Limitations Results cannot be inferred to show causality and may not be generalizable to women or the general US population. Conclusions Lower predialysis SBP is associated with higher all-cause mortality in the immediate postdialysis period. Predialysis DBP showed no consistent association with postdialysis mortality. Further studies are needed to clarify ideal predialysis SBP levels among incident dialysis patients as a potential means to improve the excessively high early dialysis mortality.

Original languageEnglish (US)
Pages (from-to)207-217
Number of pages11
JournalAmerican Journal of Kidney Diseases
Volume70
Issue number2
DOIs
StatePublished - Aug 2017

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Dialysis
Maintenance
Blood Pressure
Mortality
Therapeutics
Medication Adherence
Veterans
Glomerular Filtration Rate
Causality
Observational Studies
Blood Vessels
Body Mass Index
Demography
Population

All Science Journal Classification (ASJC) codes

  • Nephrology

Cite this

Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality. / Sumida, Keiichi; Molnar, Miklos Z.; Potukuchi, Praveen K.; Thomas, Fridtjof; Lu, Jun Ling; Ravel, Vanessa A.; Soohoo, Melissa; Rhee, Connie M.; Streja, Elani; Sim, John J.; Yamagata, Kunihiro; Kalantar-Zadeh, Kamyar; Kovesdy, Csaba P.

In: American Journal of Kidney Diseases, Vol. 70, No. 2, 08.2017, p. 207-217.

Research output: Contribution to journalArticle

Sumida, K, Molnar, MZ, Potukuchi, PK, Thomas, F, Lu, JL, Ravel, VA, Soohoo, M, Rhee, CM, Streja, E, Sim, JJ, Yamagata, K, Kalantar-Zadeh, K & Kovesdy, CP 2017, 'Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality', American Journal of Kidney Diseases, vol. 70, no. 2, pp. 207-217. https://doi.org/10.1053/j.ajkd.2016.12.020
Sumida, Keiichi ; Molnar, Miklos Z. ; Potukuchi, Praveen K. ; Thomas, Fridtjof ; Lu, Jun Ling ; Ravel, Vanessa A. ; Soohoo, Melissa ; Rhee, Connie M. ; Streja, Elani ; Sim, John J. ; Yamagata, Kunihiro ; Kalantar-Zadeh, Kamyar ; Kovesdy, Csaba P. / Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality. In: American Journal of Kidney Diseases. 2017 ; Vol. 70, No. 2. pp. 207-217.
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abstract = "Background Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown. Study Design Observational study. Setting & Participants 17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years. Predictor Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to ≥160 mm Hg in 10−mm Hg increments) and 5 (<60 to ≥90 mm Hg in 10−mm Hg increments) categories, respectively, and as continuous measures. Outcomes & Measurements Postdialysis all-cause mortality, assessed over different follow-up periods (ie, <3, 3-<6, 6-<12, and ≥12 months after dialysis therapy initiation) using Cox regressions adjusted for demographics, comorbid conditions, medications, cardiovascular medication adherence, body mass index, estimated glomerular filtration rate, and type of vascular access. Results Mean predialysis SBP and DBP were 141.2 ± 16.1 (SD) and 73.7 ± 10.6 mm Hg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP < 140 mm Hg. Mortality risks associated with lower SBP were greatest in the first 3 months after dialysis therapy initiation, with multivariable-adjusted HRs of 2.40 (95{\%} CI, 1.96-2.93), 1.99 (95{\%} CI, 1.66-2.40), 1.35 (95{\%} CI, 1.13-1.62), 0.98 (95{\%} CI, 0.78-1.22), and 0.76 (95{\%} CI, 0.57-1.00) for SBP <120, 120 to <130, 130 to <140, 150 to <160, and ≥160 (vs 140-<150) mm Hg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality. Limitations Results cannot be inferred to show causality and may not be generalizable to women or the general US population. Conclusions Lower predialysis SBP is associated with higher all-cause mortality in the immediate postdialysis period. Predialysis DBP showed no consistent association with postdialysis mortality. Further studies are needed to clarify ideal predialysis SBP levels among incident dialysis patients as a potential means to improve the excessively high early dialysis mortality.",
author = "Keiichi Sumida and Molnar, {Miklos Z.} and Potukuchi, {Praveen K.} and Fridtjof Thomas and Lu, {Jun Ling} and Ravel, {Vanessa A.} and Melissa Soohoo and Rhee, {Connie M.} and Elani Streja and Sim, {John J.} and Kunihiro Yamagata and Kamyar Kalantar-Zadeh and Kovesdy, {Csaba P.}",
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T1 - Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality

AU - Sumida, Keiichi

AU - Molnar, Miklos Z.

AU - Potukuchi, Praveen K.

AU - Thomas, Fridtjof

AU - Lu, Jun Ling

AU - Ravel, Vanessa A.

AU - Soohoo, Melissa

AU - Rhee, Connie M.

AU - Streja, Elani

AU - Sim, John J.

AU - Yamagata, Kunihiro

AU - Kalantar-Zadeh, Kamyar

AU - Kovesdy, Csaba P.

PY - 2017/8

Y1 - 2017/8

N2 - Background Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown. Study Design Observational study. Setting & Participants 17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years. Predictor Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to ≥160 mm Hg in 10−mm Hg increments) and 5 (<60 to ≥90 mm Hg in 10−mm Hg increments) categories, respectively, and as continuous measures. Outcomes & Measurements Postdialysis all-cause mortality, assessed over different follow-up periods (ie, <3, 3-<6, 6-<12, and ≥12 months after dialysis therapy initiation) using Cox regressions adjusted for demographics, comorbid conditions, medications, cardiovascular medication adherence, body mass index, estimated glomerular filtration rate, and type of vascular access. Results Mean predialysis SBP and DBP were 141.2 ± 16.1 (SD) and 73.7 ± 10.6 mm Hg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP < 140 mm Hg. Mortality risks associated with lower SBP were greatest in the first 3 months after dialysis therapy initiation, with multivariable-adjusted HRs of 2.40 (95% CI, 1.96-2.93), 1.99 (95% CI, 1.66-2.40), 1.35 (95% CI, 1.13-1.62), 0.98 (95% CI, 0.78-1.22), and 0.76 (95% CI, 0.57-1.00) for SBP <120, 120 to <130, 130 to <140, 150 to <160, and ≥160 (vs 140-<150) mm Hg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality. Limitations Results cannot be inferred to show causality and may not be generalizable to women or the general US population. Conclusions Lower predialysis SBP is associated with higher all-cause mortality in the immediate postdialysis period. Predialysis DBP showed no consistent association with postdialysis mortality. Further studies are needed to clarify ideal predialysis SBP levels among incident dialysis patients as a potential means to improve the excessively high early dialysis mortality.

AB - Background Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown. Study Design Observational study. Setting & Participants 17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years. Predictor Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to ≥160 mm Hg in 10−mm Hg increments) and 5 (<60 to ≥90 mm Hg in 10−mm Hg increments) categories, respectively, and as continuous measures. Outcomes & Measurements Postdialysis all-cause mortality, assessed over different follow-up periods (ie, <3, 3-<6, 6-<12, and ≥12 months after dialysis therapy initiation) using Cox regressions adjusted for demographics, comorbid conditions, medications, cardiovascular medication adherence, body mass index, estimated glomerular filtration rate, and type of vascular access. Results Mean predialysis SBP and DBP were 141.2 ± 16.1 (SD) and 73.7 ± 10.6 mm Hg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP < 140 mm Hg. Mortality risks associated with lower SBP were greatest in the first 3 months after dialysis therapy initiation, with multivariable-adjusted HRs of 2.40 (95% CI, 1.96-2.93), 1.99 (95% CI, 1.66-2.40), 1.35 (95% CI, 1.13-1.62), 0.98 (95% CI, 0.78-1.22), and 0.76 (95% CI, 0.57-1.00) for SBP <120, 120 to <130, 130 to <140, 150 to <160, and ≥160 (vs 140-<150) mm Hg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality. Limitations Results cannot be inferred to show causality and may not be generalizable to women or the general US population. Conclusions Lower predialysis SBP is associated with higher all-cause mortality in the immediate postdialysis period. Predialysis DBP showed no consistent association with postdialysis mortality. Further studies are needed to clarify ideal predialysis SBP levels among incident dialysis patients as a potential means to improve the excessively high early dialysis mortality.

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