Association of intradialytic blood pressure variability with increased all-cause and cardiovascular mortality in patients treated with long-term hemodialysis

Jennifer E. Flythe, Jula K. Inrig, Tariq Shafi, Tara I. Chang, Kathryn Cape, Kumar Dinesh, Shrikanth Kunaparaju, Steven M. Brunelli

Research output: Contribution to journalArticle

Abstract

Background: Blood pressure is known to fluctuate widely during hemodialysis; however, little is known about the association between intradialytic blood pressure variability and outcomes. Study Design: Retrospective observational cohort. Setting & Participants: A random sample of 6,393 adult, thrice-weekly, in-center, maintenance hemodialysis patients dialyzing at 1,026 dialysis units within a single large dialysis organization. Predictor: Intradialytic systolic blood pressure (SBP) variability. This was calculated using a mixed linear effects model. Peridialytic SBP phenomena were defined as starting SBP (regression intercept), systematic change in SBP over the course of dialysis (2 regression slopes), and random intradialytic SBP variability (absolute regression residual). Outcomes: All-cause and cardiovascular mortality. Measurements: SBPs (n = 631,922) measured during hemodialysis treatments (n = 78,961) during the first 30 days in the study. Outcome data were obtained from the dialysis unit electronic medical record and were considered beginning on day 31. Results: High (ie, greater than the median) versus low SBP variability was associated with greater risk of all-cause mortality (adjusted HR, 1.26; 95% CI, 1.08-1.47). The association between high SBP variability and cardiovascular mortality was even more potent (adjusted HR, 1.32; 95% CI, 1.01-1.72). A dose-response trend was observed across quartiles of SBP variability for both all-cause (P = 0.001) and cardiovascular (P = 0.04) mortality. Limitations: Inclusion of patients from a single large dialysis organization, over-representation of African Americans and patients with diabetes and heart failure, and lack of standardized SBP measurements. Conclusions: Greater intradialytic SBP variability is associated independently with increased all-cause and cardiovascular mortality. Further prospective studies are needed to confirm findings and identify means of reducing SBP variability to facilitate randomized study.

Original languageEnglish (US)
Pages (from-to)966-974
Number of pages9
JournalAmerican Journal of Kidney Diseases
Volume61
Issue number6
DOIs
StatePublished - Jun 2013

Fingerprint

Renal Dialysis
Blood Pressure
Mortality
Dialysis
Organizations
Electronic Health Records

Keywords

  • blood pressure
  • Hemodialysis
  • mortality
  • variability

ASJC Scopus subject areas

  • Nephrology

Cite this

Association of intradialytic blood pressure variability with increased all-cause and cardiovascular mortality in patients treated with long-term hemodialysis. / Flythe, Jennifer E.; Inrig, Jula K.; Shafi, Tariq; Chang, Tara I.; Cape, Kathryn; Dinesh, Kumar; Kunaparaju, Shrikanth; Brunelli, Steven M.

In: American Journal of Kidney Diseases, Vol. 61, No. 6, 06.2013, p. 966-974.

Research output: Contribution to journalArticle

Flythe, Jennifer E. ; Inrig, Jula K. ; Shafi, Tariq ; Chang, Tara I. ; Cape, Kathryn ; Dinesh, Kumar ; Kunaparaju, Shrikanth ; Brunelli, Steven M. / Association of intradialytic blood pressure variability with increased all-cause and cardiovascular mortality in patients treated with long-term hemodialysis. In: American Journal of Kidney Diseases. 2013 ; Vol. 61, No. 6. pp. 966-974.
@article{a5cdca05eb0d4e568dd98c9e2c053880,
title = "Association of intradialytic blood pressure variability with increased all-cause and cardiovascular mortality in patients treated with long-term hemodialysis",
abstract = "Background: Blood pressure is known to fluctuate widely during hemodialysis; however, little is known about the association between intradialytic blood pressure variability and outcomes. Study Design: Retrospective observational cohort. Setting & Participants: A random sample of 6,393 adult, thrice-weekly, in-center, maintenance hemodialysis patients dialyzing at 1,026 dialysis units within a single large dialysis organization. Predictor: Intradialytic systolic blood pressure (SBP) variability. This was calculated using a mixed linear effects model. Peridialytic SBP phenomena were defined as starting SBP (regression intercept), systematic change in SBP over the course of dialysis (2 regression slopes), and random intradialytic SBP variability (absolute regression residual). Outcomes: All-cause and cardiovascular mortality. Measurements: SBPs (n = 631,922) measured during hemodialysis treatments (n = 78,961) during the first 30 days in the study. Outcome data were obtained from the dialysis unit electronic medical record and were considered beginning on day 31. Results: High (ie, greater than the median) versus low SBP variability was associated with greater risk of all-cause mortality (adjusted HR, 1.26; 95{\%} CI, 1.08-1.47). The association between high SBP variability and cardiovascular mortality was even more potent (adjusted HR, 1.32; 95{\%} CI, 1.01-1.72). A dose-response trend was observed across quartiles of SBP variability for both all-cause (P = 0.001) and cardiovascular (P = 0.04) mortality. Limitations: Inclusion of patients from a single large dialysis organization, over-representation of African Americans and patients with diabetes and heart failure, and lack of standardized SBP measurements. Conclusions: Greater intradialytic SBP variability is associated independently with increased all-cause and cardiovascular mortality. Further prospective studies are needed to confirm findings and identify means of reducing SBP variability to facilitate randomized study.",
keywords = "blood pressure, Hemodialysis, mortality, variability",
author = "Flythe, {Jennifer E.} and Inrig, {Jula K.} and Tariq Shafi and Chang, {Tara I.} and Kathryn Cape and Kumar Dinesh and Shrikanth Kunaparaju and Brunelli, {Steven M.}",
year = "2013",
month = "6",
doi = "10.1053/j.ajkd.2012.12.023",
language = "English (US)",
volume = "61",
pages = "966--974",
journal = "American Journal of Kidney Diseases",
issn = "0272-6386",
publisher = "W.B. Saunders Ltd",
number = "6",

}

TY - JOUR

T1 - Association of intradialytic blood pressure variability with increased all-cause and cardiovascular mortality in patients treated with long-term hemodialysis

AU - Flythe, Jennifer E.

AU - Inrig, Jula K.

AU - Shafi, Tariq

AU - Chang, Tara I.

AU - Cape, Kathryn

AU - Dinesh, Kumar

AU - Kunaparaju, Shrikanth

AU - Brunelli, Steven M.

PY - 2013/6

Y1 - 2013/6

N2 - Background: Blood pressure is known to fluctuate widely during hemodialysis; however, little is known about the association between intradialytic blood pressure variability and outcomes. Study Design: Retrospective observational cohort. Setting & Participants: A random sample of 6,393 adult, thrice-weekly, in-center, maintenance hemodialysis patients dialyzing at 1,026 dialysis units within a single large dialysis organization. Predictor: Intradialytic systolic blood pressure (SBP) variability. This was calculated using a mixed linear effects model. Peridialytic SBP phenomena were defined as starting SBP (regression intercept), systematic change in SBP over the course of dialysis (2 regression slopes), and random intradialytic SBP variability (absolute regression residual). Outcomes: All-cause and cardiovascular mortality. Measurements: SBPs (n = 631,922) measured during hemodialysis treatments (n = 78,961) during the first 30 days in the study. Outcome data were obtained from the dialysis unit electronic medical record and were considered beginning on day 31. Results: High (ie, greater than the median) versus low SBP variability was associated with greater risk of all-cause mortality (adjusted HR, 1.26; 95% CI, 1.08-1.47). The association between high SBP variability and cardiovascular mortality was even more potent (adjusted HR, 1.32; 95% CI, 1.01-1.72). A dose-response trend was observed across quartiles of SBP variability for both all-cause (P = 0.001) and cardiovascular (P = 0.04) mortality. Limitations: Inclusion of patients from a single large dialysis organization, over-representation of African Americans and patients with diabetes and heart failure, and lack of standardized SBP measurements. Conclusions: Greater intradialytic SBP variability is associated independently with increased all-cause and cardiovascular mortality. Further prospective studies are needed to confirm findings and identify means of reducing SBP variability to facilitate randomized study.

AB - Background: Blood pressure is known to fluctuate widely during hemodialysis; however, little is known about the association between intradialytic blood pressure variability and outcomes. Study Design: Retrospective observational cohort. Setting & Participants: A random sample of 6,393 adult, thrice-weekly, in-center, maintenance hemodialysis patients dialyzing at 1,026 dialysis units within a single large dialysis organization. Predictor: Intradialytic systolic blood pressure (SBP) variability. This was calculated using a mixed linear effects model. Peridialytic SBP phenomena were defined as starting SBP (regression intercept), systematic change in SBP over the course of dialysis (2 regression slopes), and random intradialytic SBP variability (absolute regression residual). Outcomes: All-cause and cardiovascular mortality. Measurements: SBPs (n = 631,922) measured during hemodialysis treatments (n = 78,961) during the first 30 days in the study. Outcome data were obtained from the dialysis unit electronic medical record and were considered beginning on day 31. Results: High (ie, greater than the median) versus low SBP variability was associated with greater risk of all-cause mortality (adjusted HR, 1.26; 95% CI, 1.08-1.47). The association between high SBP variability and cardiovascular mortality was even more potent (adjusted HR, 1.32; 95% CI, 1.01-1.72). A dose-response trend was observed across quartiles of SBP variability for both all-cause (P = 0.001) and cardiovascular (P = 0.04) mortality. Limitations: Inclusion of patients from a single large dialysis organization, over-representation of African Americans and patients with diabetes and heart failure, and lack of standardized SBP measurements. Conclusions: Greater intradialytic SBP variability is associated independently with increased all-cause and cardiovascular mortality. Further prospective studies are needed to confirm findings and identify means of reducing SBP variability to facilitate randomized study.

KW - blood pressure

KW - Hemodialysis

KW - mortality

KW - variability

UR - http://www.scopus.com/inward/record.url?scp=84877926068&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84877926068&partnerID=8YFLogxK

U2 - 10.1053/j.ajkd.2012.12.023

DO - 10.1053/j.ajkd.2012.12.023

M3 - Article

C2 - 23474007

AN - SCOPUS:84877926068

VL - 61

SP - 966

EP - 974

JO - American Journal of Kidney Diseases

JF - American Journal of Kidney Diseases

SN - 0272-6386

IS - 6

ER -