Home Blood Pressure Phenotypes and Cardiovascular Remodeling in Hemodialysis

Introduction: Dialysis-unit blood pressure (BP) incompletely reflects the true BP burden in hemodialysis (HD), yet the clinical significance of BP phenotypes, particularly white-coat and masked patterns, remains uncertain. We examined associations between BP phenotypes defined by dialysis-unit and home BP and cardiac and vascular remodeling in maintenance HD. Methods: In 217 adults receiving thrice-weekly HD, BP phenotypes were classified using predialysis BP (≥ 140/90 mm Hg) and standardized 7-day home BP (≥ 135/85 mm Hg) as sustained normotension (SNT), white-coat phenotype (WCH), masked hypertension (MHT), and sustained hypertension (SHT). The primary outcomes were left ventricular hypertrophy (LVH) and arterial stiffness (brachial-ankle pulse wave velocity [PWV, baPWV] ≥ 1800 cm/s). Multivariable logistic regression was adjusted for demographic and dialysis-specific covariates, with sensitivity analyses using alternative BP thresholds. Results: Phenotype distribution was 29.5% SNT, 24.0% WCH, 6.9% MHT, and 39.6% SHT; nearly one-third of patients were misclassified by dialysis-unit BP alone. Compared with SNT, SHT was independently associated with LVH and arterial stiffness, whereas MHT showed the strongest association with arterial stiffness. WCH was not associated with LVH overall, but was associated with higher arterial stiffness. In stratified analyses, arterial stiffness increased across phenotypes regardless of treatment status, whereas excess LVH in WCH was observed only among untreated patients. Conclusion: Home BP-based phenotyping reveals substantial misclassification by dialysis-unit BP and distinct patterns of cardiac and vascular remodeling in HD. Although SHT and MHT confer the greatest structural burden, WCH, particularly when untreated, is not entirely benign, highlighting the value of standardized home BP monitoring in dialysis care.