What is the clinical evidence from this study?

Study design: Cohort. Population: Hemodialysis (n=3436). Intervention: Pre-dialysis systolic blood pressure <134 mm Hg vs. Pre-dialysis systolic blood pressure 148-158 mm Hg. Primary outcome: All-cause mortality (HR 1.83, 95% CI 1.40-2.39, p=<0.001).

December 1, 2018Open Access

Prognostic value of pre-dialysis blood pressure and risk threshold on clinical outcomes in hemodialysis patients

Q: What are the key findings of this study?

The lowest quintile of pre-dialysis systolic blood pressure (<134 mm Hg) was associated with a significantly increased risk of all-cause mortality (HR 1.83) compared to the reference group (148-158 mm Hg).

Key Result

The lowest quintile of pre-dialysis systolic blood pressure (<134 mm Hg) was associated with a significantly increased risk of all-cause mortality (HR 1.83) compared to the reference group (148-158 mm Hg).

Study Design

Type

Cohort (n=3,436)

Multicenter

Yes

Structured PICO

Does pre-dialysis blood pressure level predict all-cause mortality and cardiovascular events in hemodialysis patients?

Population

3,436 adult outpatients undergoing hemodialysis in Japan, followed prospectively for 4 years to assess the association between pre-dialysis blood pressure and clinical outcomes.

Exposure

Pre-dialysis blood pressure levels (systolic and diastolic) categorized into quintiles

Comparator

Reference blood pressure quintiles (Quintile 3 for SBP [148 to 158 mm Hg] and Quintile 2 for DBP [66 to 72 mm Hg])

Outcome

All-cause deathhard clinical

Pre-dialysis blood pressure exhibits a U-shaped association with mortality and cardiovascular events in hemodialysis patients, suggesting optimal targets (SBP ~152 mm Hg) may be higher than those recommended for the general population.

Main Result

Hazard Ratio: 1.83 (95% CI 1.4–2.39)

p-value: p=<0.001

Limitations

Blood pressure data were collected at only the baseline examination.
Lack of data on body fluid volume, arterial stiffness, and vascular calcification at baseline.
Intra-dialysis blood pressure values were not collected.
Lack of data on comorbidities such as heart failure or liver cirrhosis.
Lack of data on cause-specific cardiovascular death.
Observational design limits determination of causality.

Abstract

The influence of pre-dialysis blood pressure (BP) on the prognosis of hemodialysis (HD) patients is still inconclusive.A total of 3436 HD patients were prospectively followed up for 4 years. The patients were divided into quintiles of pre-dialysis systolic BP (SBP) and diastolic BP (DBP) levels mm Hg: Quintile 1 (Q1), SBP <134, DBP <66; Q2, SBP 134 to 147, DBP 66 to 72; Q3, SBP 148 to 158, DBP 73 to 79; Q4, SBP 159 to 171, DBP 80 to 85; Q5, SBP ≥172, DBP ≥86. The association between the pre-dialysis BP and outcomes were examined using a Cox proportional hazards model.During a 4-year follow-up period, 564 (16.4%) patients died of any cause and 590 (17.2%) developed cardiovascular (CV) events. The lowest level of pre-dialysis SBP group (Q1) showed a significantly increased risk of all-cause mortality (hazard ratio HR 1.83, 95% confidence interval CI 1.40-2.39) and the highest group (Q5) significantly increased risk of CV events (HR 1.31, 95% CI 1.02-1.68) compared with the reference group (Q3), respectively. The highest level of pre-dialysis DBP group was significantly associated with increased risk for both all-cause mortality and CV events. Restricted cubic spline analysis for BP and outcomes suggested the optimal pre-dialysis BP value associated with the lowest risk of outcomes was SBP 152 mm Hg for all-cause mortality, SBP 143 mm Hg for CV events, and DBP 68 mm Hg for all-cause mortality.Our results suggested that pre-dialysis BP was independently associated with all-cause mortality and CV events among Japanese HD patients.

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