Intradialytic hypotension, blood pressure changes and mortality risk in incident hemodialysis patients

Jason A. Chou, Elani Streja, Danh V. Nguyen, Connie M. Rhee, Yoshitsugu Obi, Jula K. Inrig, Alpesh Amin, Csaba Kovesdy, John J. Sim, Kamyar Kalantar-Zadeh

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Abstract

Background. Intradialytic hypotension (IDH) occurs frequently inmaintenance hemodialysis (HD) patients and may be associated with higher mortality. We hypothesize that nadir intradialytic systolic blood pressure (niSBP) is inversely related to death risk while iSBP change (D) and IDH frequency are incrementally associated with all-cause mortality. Methods. In a US-based cohort of 112 013 incident HD patients over a 5-year period (2007-11), using niSBP, DiSBP (pre-HD SBP minus niSBP) and IDH frequency (proportion of HD treatments with niSBP <90mmHg) within the first 91 days of HD, we examined mortality-predictability at 1, 2 and 5 years using Cox models and restricted cubic splines adjusted for case-mix, comorbidities and laboratory covariates. Results. We observed that niSBP of <90 and 140mmHg had a 5-year mortality hazard ratio (HR) (95% confidence interval) of 1.57 (1.47-1.67) and 1.25 (1.18-1.33), respectively, compared with niSBP 110 to <120mmHg. DiSBP of <15 and 50 compared with 21-30mmHg had mortality HR of 1.31 (1.26-1.37) and 1.32 (1.24-1.39), respectively. Among patients with >40% IDH frequency, we observed a mortality HR of 1.49 (1.42-1.57) compared with 0% IDH frequency in fully adjusted models. These associations were robust at 1 and 2 years of follow-up. Conclusion. In conclusion, we observed a U-shaped association between niSBP and DiSBP andmortality and a direct linear relationship between IDH frequency and mortality. Our findings lend some prognostic insight of HD blood pressure and hemodynamics, and have the potential to guide blood pressure management strategies among the HD population.

Original languageEnglish (US)
Pages (from-to)149-159
Number of pages11
JournalNephrology Dialysis Transplantation
Volume33
Issue number1
DOIs
StatePublished - Jan 1 2018

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Hypotension
Renal Dialysis
Blood Pressure
Mortality
Hemodynamics

All Science Journal Classification (ASJC) codes

  • Nephrology
  • Transplantation

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Chou, J. A., Streja, E., Nguyen, D. V., Rhee, C. M., Obi, Y., Inrig, J. K., ... Kalantar-Zadeh, K. (2018). Intradialytic hypotension, blood pressure changes and mortality risk in incident hemodialysis patients. Nephrology Dialysis Transplantation, 33(1), 149-159. https://doi.org/10.1093/ndt/gfx037

Intradialytic hypotension, blood pressure changes and mortality risk in incident hemodialysis patients. / Chou, Jason A.; Streja, Elani; Nguyen, Danh V.; Rhee, Connie M.; Obi, Yoshitsugu; Inrig, Jula K.; Amin, Alpesh; Kovesdy, Csaba; Sim, John J.; Kalantar-Zadeh, Kamyar.

In: Nephrology Dialysis Transplantation, Vol. 33, No. 1, 01.01.2018, p. 149-159.

Research output: Contribution to journalArticle

Chou, JA, Streja, E, Nguyen, DV, Rhee, CM, Obi, Y, Inrig, JK, Amin, A, Kovesdy, C, Sim, JJ & Kalantar-Zadeh, K 2018, 'Intradialytic hypotension, blood pressure changes and mortality risk in incident hemodialysis patients', Nephrology Dialysis Transplantation, vol. 33, no. 1, pp. 149-159. https://doi.org/10.1093/ndt/gfx037
Chou, Jason A. ; Streja, Elani ; Nguyen, Danh V. ; Rhee, Connie M. ; Obi, Yoshitsugu ; Inrig, Jula K. ; Amin, Alpesh ; Kovesdy, Csaba ; Sim, John J. ; Kalantar-Zadeh, Kamyar. / Intradialytic hypotension, blood pressure changes and mortality risk in incident hemodialysis patients. In: Nephrology Dialysis Transplantation. 2018 ; Vol. 33, No. 1. pp. 149-159.
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AU - Streja, Elani

AU - Nguyen, Danh V.

AU - Rhee, Connie M.

AU - Obi, Yoshitsugu

AU - Inrig, Jula K.

AU - Amin, Alpesh

AU - Kovesdy, Csaba

AU - Sim, John J.

AU - Kalantar-Zadeh, Kamyar

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AB - Background. Intradialytic hypotension (IDH) occurs frequently inmaintenance hemodialysis (HD) patients and may be associated with higher mortality. We hypothesize that nadir intradialytic systolic blood pressure (niSBP) is inversely related to death risk while iSBP change (D) and IDH frequency are incrementally associated with all-cause mortality. Methods. In a US-based cohort of 112 013 incident HD patients over a 5-year period (2007-11), using niSBP, DiSBP (pre-HD SBP minus niSBP) and IDH frequency (proportion of HD treatments with niSBP <90mmHg) within the first 91 days of HD, we examined mortality-predictability at 1, 2 and 5 years using Cox models and restricted cubic splines adjusted for case-mix, comorbidities and laboratory covariates. Results. We observed that niSBP of <90 and 140mmHg had a 5-year mortality hazard ratio (HR) (95% confidence interval) of 1.57 (1.47-1.67) and 1.25 (1.18-1.33), respectively, compared with niSBP 110 to <120mmHg. DiSBP of <15 and 50 compared with 21-30mmHg had mortality HR of 1.31 (1.26-1.37) and 1.32 (1.24-1.39), respectively. Among patients with >40% IDH frequency, we observed a mortality HR of 1.49 (1.42-1.57) compared with 0% IDH frequency in fully adjusted models. These associations were robust at 1 and 2 years of follow-up. Conclusion. In conclusion, we observed a U-shaped association between niSBP and DiSBP andmortality and a direct linear relationship between IDH frequency and mortality. Our findings lend some prognostic insight of HD blood pressure and hemodynamics, and have the potential to guide blood pressure management strategies among the HD population.

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