Age-related Blood Pressure Patterns and Blood Pressure Variability among Hemodialysis Patients

Background and objectives: Despite the high prevalence of cardiovascular disease among hemodialysis patients, the relationship between age and blood pressure (BP) is not well understood. It was postulated that the relationship of BP to age differs among hemodialysis patients versus the general population and that there is significant variability in dialysis unit BP measurements.Design, setting, participants, & measurements: To explore this hypothesis, the patterns of systolic, diastolic, mean arterial, and pulse pressures in the general population using data from National Health and Nutrition Examination Survey participants (n = 9242) were compared with those in a cohort of hemodialysis patients (n = 9849).Results: In contrast to the increase in systolic BP with age in the general population, systolic BP was elevated in young hemodialysis patients and declined slightly among the elderly. The inverted “U”-shape relationship between age and diastolic BP in the general population was absent in hemodialysis patients. Diastolic BP was elevated among hemodialysis patients <50 yr of age and declined with advancing age. Mean arterial and pulse pressures were elevated among young hemodialysis patients and exhibited less age dependency than in the general population. Variability in BP within patients was similar to that between patients.Conclusions: The relationship of BP to age differed from that in the general population. The variability in dialysis unit BP measurements may limit their use in managing hypertension and predicting outcomes. Nevertheless, dialysis unit BP measurements are necessary to minimize acute complications during the dialysis procedure.The National Health and Nutritional Examination Survey (NHANES) (1) and the Framingham Study (2) have contributed significantly to our understanding of the relationships between aging, blood pressure (BP), and cardiovascular disease (CVD). Unfortunately, these relationships have been less well characterized among hemodialysis (HD) patients despite their high prevalence of CVD (3). Although hypertension is a modifiable risk factor for CVD mortality in the general population, epidemiologic studies have failed to confirm similar relationships among HD patients. Observational data have suggested that HD patients with systolic BP (SBP) between 150 and 159 mmHg experience lower mortality than their normotensive peers, and there has been no evidence of increased mortality until SBP ≥180 mmHg (4–7). Speculation about the seemingly paradoxical relationship between BP and mortality has centered on the high prevalence of left ventricular systolic dysfunction; however, definitive prospective studies are lacking (3,8–11).The NHANES and Framingham Studies demonstrated that steady increases in SBP and gradual declines in diastolic BP (DBP) accompany aging in the general population. Hypertensive subjects <50 yr of age in the general population usually exhibit systolic and diastolic hypertension and a narrowed pulse pressure (PP), reflecting increased peripheral vascular resistance. Additionally, older individuals tend to exhibit isolated systolic hypertension and an elevated PP, reflecting reduced elastic artery compliance. Among HD patients, limited observational data indicate that the relationships between BP and age may differ from that of the general population (12–14). However, a rigorous analysis analogous to the NHANES survey investigating these relationships has not been previously published. The high prevalence of accelerated vascular disease and left ventricular hypertrophy among young HD patients is consistent with the hypothesis that BP patterns may be similar to those found in older members of the general population.Several recent studies have suggested that routine measurement of BP within the dialysis unit may have limited utility in the management of hypertension and in predicting clinical outcomes (15–17). These findings are consistent with the hypothesis that there may be significant variability in routine BP measurements made in the dialysis unit.The present study explored age-dependent BP parameters among HD patients as compared with the general population by addressing the following questions: 1) Do the relationships between age and BP measurements differ and if so how? 2) How variable are the values for different BP parameters within individual HD patients and across HD patients?     

Assessment of Dialysis Dose in Critically Ill Maintenance Dialysis Patients

Maintenance dialysis patients are admitted more frequently to the intensive care unit (ICU) and have higher ICU mortality than the general population. It is unclear if such dialysis patients receive adequate dialysis in the ICU setting. Using the Daugirdas formula for calculation of spKt/Vurea, single treatment delivered dialysis dose was assessed in 85 critically ill maintenance hemodialysis patients during their first ICU dialysis session. Weekly delivered spKt/Vurea was determined in the surviving 64 patients and compared with their corresponding delivered outpatient dialysis dosages. Outcome measures were ICU and in‐hospital mortality and mortality at 6 and 12 months after discharge. Prescribed dose of the first ICU dialysis was a spKt/Vurea of 1.43 ± 0.11, the single treatment delivered dose was 1.02 ± 0.14. The weekly prescribed ICU Kt/Vurea was 4.25 ± 0.12 and delivered ICU Kt/Vurea was 3.48 ± 0.19. Patients with sepsis had the lowest mean spKt/Vurea values (0.87 ± 0.12). Serial measurements of delivered dialysis dose suggest that this gap is explained by variability of volume of urea distribution. ICU mortality was 25% and was related to APACHE II score, but not to delivered intermittent hemodialysis dose. Critically ill maintenance dialysis patients receive suboptimal dialysis doses. The impact of short‐term underdialysis on survival of hospitalized maintenance dialysis patients remains unknown. Assessment of dialysis adequacy should be routinely performed in these patients and delivered dialysis should be tracked through the initial clinical course.     

Body mass index-mortality paradox in hemodialysis: can it be explained by blood pressure?

Unlike the general population, among hemodialysis patients body mass index (BMI) is related to blood pressure (BP) and mortality inversely. To explore the reasons for this risk-factor paradox, the cross-sectional association of obesity with the following factors was examined: the prevalence of hypertension, its control, and echocardiographic left ventricular mass index (LVMI). Longitudinal follow-up explored the relationship of BMI with all-cause mortality. Furthermore, it explored whether poorer survival in leaner individuals was related to either high BP or greater LVMI. Among 368 hemodialysis patients, both the prevalence of hypertension and its poor control were inversely related to BMI. BMI was also inversely associated with evidence of excess extracellular fluid volume, but adjustment for this variable did not completely remove the inverse relationship between BP and BMI. Over 1122 patient-years of cumulative follow-up (median: 2.7 years), 119 patients (32%) died. In the first 2 years of follow-up, the mortality hazard for the lowest BMI group was increased; thereafter, the survival curves were similar. Adjusting for several risk factors including BP and LVMI did not remove the inverse relationship of BMI with mortality. In conclusion, leaner patients on dialysis have a higher prevalence of hypertension, poorer control of hypertension, more LVMI, and greater evidence of extracellular fluid volume excess. However, volume explains the greater prevalence or poorer control of hypertension only partially. Leaner patients have an accelerated mortality rate in the first 2 years; this is not completely explained by BP, LVMI, or other cardiovascular or dialysis-specific risk factors.     

New‐Onset Diabetes Mellitus in Peritoneal Dialysis and Hemodialysis Patients: Frequency,Risk Factors,and Prognosis—A Review

New‐onset diabetes mellitus (NODM) is observed in both hemodialysis (HD) and peritoneal dialysis (PD) patients. The prevalence of NODM in dialysis patients is slightly higher compared to subjects of the general population. Based on currently published data there is no convincing evidence that the risk of NODM is different between HD and PD patients. Data on the effect of glucose load on risk of NODM in dialysis patients remain controversial. PD modality (automated or continuous ambulatory PD) has no significant influence on NODM incidence. Chronic inflammation is associated with NODM in dialysis patients. Reported differences in NODM between PD and HD patients are possibly also influenced by differences in demographic factors between these patient groups. Mortality in NODM patients is lower than mortality in patients with preexisting DM. This may be partly explained by the younger age and lower number of comorbidities in patients with NODM.     

Aortic blood pressure and arterial stiffness in patients with controlled resistant and non‐resistant hypertension

The purpose of the current study was to determine whether aortic blood pressure (BP) and arterial stiffness are greater in patients with controlled resistant hypertension (RHTN) than controlled non‐resistant hypertension (non‐RHTN) despite similar clinic BP level. Participants were recruited from University of Alabama at Birmingham (UAB) Hypertension Clinic. Controlled hypertension was defined as automated office BP measurement with BP < 135/85 mm Hg. A total of 141 participants were evaluated by pulse wave analysis (PWA) and carotid‐femoral pulse wave velocity (cf‐PWV). Among them, 75 patients had controlled RHTN with use of 4 or more antihypertensive medications and 56 patients had controlled non‐RHTN with use of 3 or less antihypertensive medications. Compared to patients with controlled non‐RHTN, those with controlled RHTN were more likely to be African American and had a higher prevalence of diabetes mellitus and congestive heart failure. The mean number of antihypertensive medications was greater in patients with controlled RHTN (4.4 ± 0.8 vs 2.3 ± 0.7, P < .001). Clinic brachial BP, aortic BP, augmentation pressure (AP), augmentation index normalized for heart rate of 75 beats per minute (AIx@75) and cf‐PWV were similar in both groups. In summary, there was no significant difference in central BP or arterial stiffness between patients with controlled RHTN and controlled non‐RHTN. These findings suggest that the higher residual cardiovascular risk observed in patients with RHTN after achieving BP control compared to patients with more easily controlled hypertension is not likely attributable to persistent differences in central BP and arterial stiffness.     

Survey of Depression by Beck Depression Inventory in Uremic Patients Undergoing Hemodialysis and Hemodiafiltration

High prevalence of depression has been reported in patients with end stage kidney disease and depression is associated with increased morbidity and mortality. We aimed to investigate the prevalence of depression in patients receiving standard hemodialysis (SHD) and hemodiafiltration (HDF) and compare the associated factors between these treatment modalities. The Beck Depression Inventory (BDI) was used to survey for major depressive symptoms. Demographic and biochemical data were reviewed and collected. Point prevalence of depression in HDF patients was significantly lower than SHD patients (23.9% vs. 43.1%, P < 0.05). The BDI score was also higher in SHD than HDF group (13.2 ± 11.6 vs. 8.7 ± 11.2, P < 0.05). SHD patients with major depressive symptoms had significantly lower levels of hemoglobin, albumin, creatinine, sodium and hand grip strength but had higher prevalence of diabetes and high sensitivity C‐reactive protein (hs‐CRP) levels. In HDF patients, phosphorus level was significantly lower in patients with major depressive symptoms. Logistic regression analysis revealed that hs‐CRP, serum sodium and hand grip strength were significantly associated with major depressive symptoms in patients treated with SHD; while serum phosphorus was identified in HDF groups. We concluded that prevalence of depression was high in dialysis patients. Patients receiving HDF had a lower mean BDI score and a nearly 50% lower prevalence rate of major depressive symptoms than that of SHD. Factors associated with depression were different between two modalities     

Trended cosinor change model for analyzing hemodynamic rhythm patterns in hemodialysis patients

To describe circadian blood pressure (BP) patterns and linear interdialytic changes, a model was developed to describe simultaneously both the straight line change and oscillatory variation in BP and heart rate over an interdialytic interval in hemodialysis patients. Using this trended cosinor model, we simultaneously compared the impact of mean level of BP, linear changes over the interdialytic interval, and oscillatory changes in BP and its relationship with antihypertensive drug use. Neither a straight-line change model nor the cosinor model adequately described the BP variability in 12,750 BP measurements from 136 chronic stable hemodialysis patients. A combination of the 2 models that allowed for the oscillatory rhythmic pattern in BP variation to have an upward trend in the interdialytic period most accurately described the data. Time elapsed since the end of dialysis demonstrated a better model fit compared with the less meaningful clock time. More antihypertensive medication use was associated with increasing mean systolic, diastolic, and pulse pressure. Although the rate of change was blunted with increasing antihypertensive drug use, the impact on oscillatory change was U-shaped for systolic BP, direct for diastolic BP, and inverse for pulse pressure. A trended cosinor model better describes the change in BP in the interdialytic interval in hemodialysis patients, especially when time elapsed is measured from the end of dialysis. Antihypertensive drugs, though associated with higher average BP, are associated with blunted rate of change in BP over time.     

Intima Media Thickness and Endothelial Function in Chronic Hemodialysis Patients

The purpose of our study was to evaluate the intima‐media thickness (IMT) of the carotid and brachial arteries, flow‐mediated dilatation (FMD), and nitroglycerin‐mediated dilatation (NMD) in diabetic and non‐diabetic hemodialysis patients. We also examined the effects of traditional and other risk factors on carotid and brachial IMT, FMD and NMD in all hemodialysis patients. Fifty‐eight adult hemodialysis patients, 14 of whom had diabetes, were studied. They had been on hemodialysis for 1–340 months. Using B‐mode ultrasonography, we measured the carotid and brachial IMT, FMD and NMD, and correlated the values with cardiovascular risk factors. FMD and NMD were significantly lower in diabetic patients (FMD 4.01 ± 0.99 vs. 6.69 ± 2.37 mm; NMD 9.1 ± 1.95 vs. 11.23 ± 2.86 mm), while no such differences were found between the two groups with respect to carotid or brachial IMT. In all patients with respect to age a positive correlation was found with carotid and brachial IMT, and a negative one with FMD and NMD. With respect to hypertension as well as diabetes, a negative correlation was found with FMD and NMD. Age is the most important factor that significantly affected all studied markers of atherosclerosis in hemodialysis patients. The endothelial and smooth vascular functions are significantly impaired in diabetic and hypertensive hemodialysis patients, and hypertension is shown to be an independent risk factor for smooth vascular dysfunction in hemodialysis patients. According to our results, intensive antihypertensive treatment is recommended in hypertensive chronic hemodialysis patients.     

Treated hypertension and the white coat phenomenon: Office readings are inadequate measures of efficacy

To better define the prevalence of white coat hypertension (WCH) among patients with type 2 diabetes mellitus and to estimate the magnitude of white coat effect (WCE), before and after antihypertensive therapy, we gathered data from an open-label forced-titration study of a combination of antihypertensive drugs that was titrated sequentially, in the order amlodipine, olmesartan, and hydrochlorothiazide, over an 18-week period among 187 patients with type 2 diabetes mellitus. WCH was defined as daytime ambulatory blood pressure (BP) of 135/85 mm Hg or less, but clinic BP of 140/90 mm Hg or more. WCE was obtained as the mean difference between clinic and daytime ambulatory BP. At baseline, the prevalence of WCH was 12%; all but one subject had WCE of >10/5 mm Hg. After treatment, the prevalence of WCH had increased to 39% (P < .001). In the overall population, at baseline, the mean (±SD) WCE for systolic BP was 10.4 ± 10.9 mm Hg and 3.7 ± 8.6 mm Hg for diastolic BP. After treatment, the reduction in systolic WCE was 3.01 ± 0.93 (SE; P < .0001); no reduction was seen for diastolic WCE. Among patients treated with amlodipine-olmesartan combination, WCE at baseline was 11 mm Hg systolic and was attenuated to -0.9 mm Hg. Among patients treated with amlodipine-olmesartan-hydrochlorothiazide combination, systolic WCE was similar at baseline (10.1 mm Hg) and at end of therapy (8.1 mm Hg). Mean systolic difference between dual and triple therapy of 9.9 mm Hg, SE 2.98 was significant (P < .001). The drop in diastolic WCE from 6.4 with dual therapy to -1.2 with triple therapy was also significant (mean difference 7.6, SE 2.2; P < .001). In conclusion, the prevalence of WCH increases three-fold with treatment as a result of fewer patients having sustained hypertension. Thus, out-of-office BP monitoring especially among treated hypertensive patients with type 2 diabetes is necessary to provide better assessment of overall BP and response to treatment.     

Tasa de ultrafiltración horaria ajustada a peso corporal y mortalidad en hemodiálisis

Background and aimsMortality among hemodialysis patients remains high. An elevated ultrafiltration rate adjusted by weight (UFR/W) has been associated with hypotension and higher risk of death and/or cardiovascular events.MethodsWe evaluated the association between UFR/W and mortality in 215 hemodialysis patients. The mean follow-up was 28 ± 6.12 months. We collected patientś baseline characteristics and mean UFR/W throughout the follow-up.ResultsMean UFR/W was 9.0 ± 2,4 and tertiles 7.1 y 10.1 mL/kg/h. We divided our population according to the percentage of sessions with UFR/W above the limits described in the literature associated with increased mortality (10.0 mL/kg/h and 13.0 mL/kg/h). Patients with higher UFR/W were younger, with higher interdialytic weight gain and weight reduction percentage but lower dry, pre and post dialysis weight. Throughout the follow-up, 46 (21.4%) patients died, the majority over 70 years old, diabetic or with cardiovascular disease. There were neither differences regarding mortality between groups nor differences in UFR/W among patients who died and those who did not. Contrary to previous studies, we did not find an association between UFR/W and mortality, maybe due to a higher prevalence in the use of cardiovascular protection drugs and lower UFR/W.ConclusionsThe highest UFR/W were observed in younger patients with lower weight and were not associated with an increased mortality.     

Hypertension in Pediatric Long-term Hemodialysis Patients in the United States

Background and objectives: Data are limited regarding BP distribution and the prevalence of hypertension in pediatric long-term dialysis patients. This study aimed to examine BP distribution in U.S. pediatric long-term hemodialysis patients.Design, setting, participants, & measurements: This cross-sectional study of all U.S. pediatric (aged 0-< 18 yr, n = 624) long-term hemodialysis patients was performed as part of the Centers for Medicare & Medicaid Services End-Stage Renal Disease (ESRD) Clinical Performance Measures Project. BP and clinical information were collected monthly in October, November, and December 2001. Hypertension was defined as the mean of pre- and postdialysis systolic or diastolic BP above the 95th percentile for age, height, and sex, or antihypertensive medication use. Results were calculated by age, sex, race, ethnicity, ESRD duration, body mass index percentile, primary cause of ESRD, and laboratory data.Results: Hypertension was present in 79% of patients; 62% used antihypertensive medication. Five percent of patients were prehypertensive (mean BP at 90th to 95th percentile). Hypertension was uncontrolled in 74% of treated patients. Characteristics associated with hypertension included acquired kidney disease, shorter duration of ESRD, and lower mean hemoglobin and calcium values. Characteristics associated with uncontrolled hypertension were younger age and shorter duration of ESRD.Conclusions: Hypertension is common in U.S. pediatric long-term hemodialysis patients, uncontrolled in 74% of treated patients, and untreated in 21% of hypertensive patients. It is concluded that a more aggressive approach to treatment of hypertension is warranted in pediatric long-term hemodialysis patients.Hypertension is present in 50% to 90% of adults receiving long-term dialysis therapy and is a risk factor for cardiovascular morbidity and mortality in this population (1–3). Although cardiovascular disease is increasingly identified as a cause of morbidity and mortality in pediatric long-term dialysis patients, few data are available regarding the distribution of BP and the prevalence of hypertension in a large pediatric long-term dialysis population, or regarding whether treated hypertension is adequately controlled (4–10).The end-stage renal disease (ESRD) Clinical Performance Measures (CPM) Project is a national quality assurance program led by the Centers for Medicare & Medicaid Services (CMS) and the 18 ESRD Networks in an effort to improve patient care for long-term dialysis patients (11). In 2002, the ESRD CPM Project collected data on all pediatric (aged 0-< 18 yr) in-center long-term hemodialysis patients in the United States who were alive on December 31, 2001. For the first time, ESRD CPM data were collected on children aged <12 yr as well as adolescents. Data were collected as part of a special study by the Cardiovascular Special Studies Center of the United States Renal Data System (USRDS). Using these data, the goals of the present study are to report distribution of BP and prevalence of hypertension in the entire U.S. pediatric in-center long-term hemodialysis population (n = 624), and to provide new data regarding factors associated with hypertension in this population.     

Diabetes acts on mortality in hemodialysis patients predicted by asymmetric dimethylarginine and inflammation

BackgroundThe mortality rate of diabetic patients on dialysis is higher than that of non-diabetic patients. Asymmetric dimethylarginine and inflammation are strong predictors of death in hemodialysis. This study aimed to evaluate asymmetric dimethylarginine and C-reactive protein interaction in predicting mortality in hemodialysis according to the presence or absence of diabetes.MethodsAsymmetric dimethylarginine and C-reactive protein were measured in 202 patients in maintenance hemodialysis assembled from 2011 to 2012 and followed for four years. Effect modification of C-reactive protein on the relationship between asymmetric dimethylarginine and all-cause mortality was investigated dividing the population into four categories according to the median of asymmetric dimethylarginine and C-reactive protein.ResultsAsymmetric dimethylarginine and C-reactive protein levels were similar between diabetics and non-diabetics. Asymmetric dimethylarginine – median IQR μM – (1.95 1.75–2.54 versus 1.03 0.81–1.55 P = 0.000) differed in non-diabetics with or without evolution to death (HR 2379 CI 1.36–3.68 P = 0.000) and was similar in diabetics without or with evolution to death. Among non-diabetics, the category with higher asymmetric dimethylarginine and C-reactive protein levels exhibited the highest mortality (69.0% P = 0.000). No differences in mortality were seen in diabetics. A joint effect was found between asymmetric dimethylarginine and C-reactive protein, explaining all-cause mortality (HR 15.21 CI 3.50–66.12 P = 0.000).ConclusionsAsymmetric dimethylarginine is an independent predictor of all-cause mortality in non-diabetic patients in hemodialysis. Other risk factors may overlap asymmetric dimethylarginine in people with diabetes. Inflammation dramatically increases the risk of death associated with high plasma asymmetric dimethylarginine in hemodialysis.     

Diastolic blood pressure is associated with brain atrophy in hemodialysis patients: A single center case–control study

Brain atrophy (BA) is often found in neuroimaging of hemodialysis patients, representing parenchymal cerebral damage. Likely contributing factors to BA are age, chronic hypertension, diabetes mellitus and other cardiovascular risk factors of atherosclerosis that are also common among hemodialysis patients. BA may also occur due to focal ischemia and hypoperfusion during hemodialysis. However, data on optimal blood pressure (BP) in these patients are limited. The goal of this study was to determine whether the prevalence and severity of BA would be higher among hemodialysis patients with lower BP. A blinded neuroradiologist graded BA of all hemodialysis patients who underwent brain non-contrast computerized tomography (CT) from 2015 to 2017 in our institution. Age- and sex-matched patients with normal kidney function who underwent brain CT during the same period and technique served as the control group. A total of 280 patients were included in this retrospective study, with average BP of 140/70 mmHg among hemodialysis patients and 142/75 mmHg in the control group. BA was more common in dialysis patients and its severity increased with age and traditional cardiovascular risk factors. We observed a significant negative correlation between diastolic BP (DBP) at dialysis initiation and BA. Average DBP decreased with increasing severity of BA. These findings were observed in both hemodialysis and non-CKD patients. BA was associated with lower DBP, which may induce cerebral hypoperfusion and ischemia. This finding should discourage over-treatment of hypertension among hemodialysis patients.     

Prognostic efficacy of cardiac biomarkers for mortality in dialysis patients

Background: The high prevalence of cardiovascular mortality in the end‐stage renal disease population is well established. The aim of this current study was to document the relative prognostic significance of established cardiac biomarkers troponin T (TnT), troponin I (TnI), B‐type natriuretic peptide (BNP) and N‐terminal pro‐BNP (NT‐pro‐BNP) in this population. Methods: A prospective cohort study of dialysis patients undertaken in a single tertiary centre in Australia. Relevant clinical and biochemical information was collected at entry and all patients followed up prospectively without any loss to follow up. End‐point of interest was all‐cause mortality. Statistical analysis using Cox proportional hazards was used to study relationship between competing covariates and outcome. A total of 143 patients with a mean age of 59.67 ± 15.49 years was followed up for a median duration of 30 months. Of these patients, 89.3% were white Australians of European ancestry. Twenty‐seven per cent had an established diagnosis of diabetes mellitus. The mean concentrations (±SD) of TnT, TnI, BNP and N‐terminal peptide pro‐BNP (NT‐pro‐BNP) were 0.08 ± 0.04 µg/L, 0.09 ± 0.2 µg/L, 270 ± 117 ng/L and 1434 ± 591 ng/L respectively. Results: Twenty‐eight subjects died during the period of follow up. By univariate analysis, all cardiac markers (TnT, TnI, BNP, NT‐pro‐BNP and C‐reactive protein) were significantly associated with an increase in mortality. On Cox proportionate hazards analysis, only albumin and NT‐pro‐BNP showed a significant association with mortality, with hazard ratios of 0.834, 95% confidence interval (CI) 0.779–0.893, P < 0.001, and 1.585, 95%CI 1.160–20165, P = 0.004 respectively. Conclusion: In patients with end‐stage renal failure on dialysis NT‐pro‐BNP provides greater prognostic information compared with TnT and TnI.     

Should All Hypertensive Dialysis Patients Receive a Blocker of the Renin-Angiotensin System?

Cardiovascular mortality and hypertension remain common in the dialysis population, and two recent meta-analyses have suggested that antihypertensive pharmacotherapy reduces cardiovascular events in dialysis patients. Based on their benefits in other populations, blockers of the renin-angiotensin-aldosterone system (RAAS) are an attractive treatment option. The evidence that RAAS blockers improve surrogate end points is mixed. However, a recent meta-analysis found significant improvement in left ventricular mass with RAAS-blocking drugs in hemodialysis patients. Only a few trials have examined RAAS-blocking drugs and cardiovascular events in dialysis patients, and a recent meta-analysis found no significant benefit in hemodialysis patients. The single trial of peritoneal dialysis patients that reported cardiovascular events found no benefit from RAAS blockers. Fortunately, the risk of hyperkalemia appears low. Based on the available evidence, we cannot categorically recommend that all hypertensive dialysis patients be treated with RAAS blockers. We await the results of adequately powered clinical trials.     

Eicosapentaenoic Acid and Prevalence of Cardiovascular Disease in Hemodialysis Patients

Eicosapentaenoic acid (EPA)/arachidonic acid (AA) ratio showed inverse associations with cardiovascular disease (CVD) in general population. However, this has not been examined enough in dialysis patients. We cross‐sectionally investigated the relationship between EPA/AA ratio and prevalence of CVD in 321 chronic hemodialysis patients (64 ± 11 years old; 110 women; dialysis vintage 10 ± 8 years) in an urban area of Tokyo. CVD was defined as a composite of ischemic heart disease, ischemic stroke and hemorrhagic stroke. The frequency of dietary fish intake was also examined. Logistic regression was used to quantify the association of EPA/AA ratio with CVD. EPA/AA ratio was 0.31 ± 0.19 and 154 patients (48%) consumed fish once or less weekly. One hundred and thirty patients (41%) had CVD, including 65 with ischemic heart disease, 70 with ischemic stroke, and 20 with hemorrhagic stroke. Age (odds ratio [OR], 1.04; P = 0.01), hypertension (OR, 2.25; P = 0.002), and dialysis vintage (OR, 1.04; P = 0.02) were associated with CVD; however, EPA/AA was not after adjustment for other risk factors. A similar relationship was observed between fish intake and CVD prevalence. We did not find any significant association between EPA/AA ratio and prevalence of CVD, although traditional risk factors such as age, hypertension and dialysis vintage were associated with CVD. These results might have been influenced by the fact that only a small proportion of our patients showed a high EPA/AA ratio.     

Renal replacement therapy for patients with diabetes mellitus in Hong Kong

Diabetes mellitus is becoming the most common cause of end-stage renal failure in Hong Kong. This review is based on data from the Hong Kong Renal Registry from 1995 through 2000. As of March 31, 2000, a total of 1026 patients with diabetes mellitus were on renal replacement therapy. A total of 809 patients had diabetic nephropathy as primary disease and 217 had diabetes mellitus as comorbidity. The prevalence of renal replacement therapy for patients with diabetes mellitus was 151 per million population. For the year ending March 31, 2000, there were 342 new patients with diabetes mellitus requiring renal replacement therapy. Of all the patients on renal replacement therapy, 23% were diabetic. The patients with diabetes mellitus were older (median age, 63 years), and had a higher incidence of hypertension (85%), ischemic heart disease (24%), cerebrovascular disease (9%), and peripheral vascular disease (3%). The modes of renal replacement therapy for patients with diabetes mellitus were peritoneal dialysis (81%), hemodialysis (9%), and transplant (10%). The annual crude mortality rate of patients with diabetes mellitus was 16% (peritoneal dialysis, 17%; hemodialysis, 18%; transplant, 1%) compared with 6% for patients without diabetes mellitus (peritoneal dialysis, 8%; hemodialysis, 12%; transplant, 1%). The major causes of death were cardiovascular disease (33%), infection (28%), and cerebrovascular event (8%). The 1-and 5-year survival rates of dibetic patient were 89% and 32% for peritoneal dialysis, 73% and 26% for hemodialysis, and 94% and 87% for transplant, respectively. The 1-and 5-year graft survival rates were 88% and 82% (death not censored), and 91% and 91% (death censored), respectively.     

Hemoglobin A1c in Patients on Peritoneal Dialysis: How Should We Interpret It?

Almost half the patients on peritoneal dialysis are diabetic and glycemic control is essential to improve both patient and technique survival. Hemoglobin A1c (HbA1c) is widely used in the general population for diabetes diagnosis and monitoring as it highly correlates with blood glucose levels and outcomes. Its use has been extrapolated to the peritoneal dialysis population, despite HbA1c being commonly underestimated. In renal failure patients, HbA1c is influenced by variables affecting not only glycemia but also hemoglobin and the time of interaction between the two. Importantly, the impact of these variables differs in peritoneal dialysis compared to non‐dialysis chronic kidney disease and hemodialysis patients. Although HbA1c in peritoneal dialysis patients is less directly associated with blood glucose levels than in the general population, studies have confirmed its association with patient mortality. In this paper we review the variables that can influence HbA1c value emphasizing their impact in peritoneal dialysis patients. By providing clinicians with a comprehensive understanding of HbA1c results, we provide them with tools for a better patient management care and potential improved outcomes of peritoneal dialysis patients.     

Real-world trends in pre-dialysis blood pressure levels of patients undergoing dialysis in Japan using a web-based national database

The prevalence of hypertension is high among patients undergoing dialysis. We extracted data of patients undergoing dialysis between 2012 and 2020 with recorded pre-dialysis systolic blood pressure (SBP) using a web-based national database in Japan. Following the 2019 Japanese Society of Hypertension guidelines, we classified SBP and assessed its trends over time based on sex, age, diabetes status, and the anti-hypertensive medication use. Using the 2020 database, we examined 336,759 Japanese patients undergoing dialysis (114,249 female; 222,510 male). The mean age was 69.4 ± 12.5 years, and the mean SBP was 152.3 ± 24.7 mm Hg. The prevalence rate of pre-dialysis hypertension was 70.2%, with 32.5%, 24.5%, and 13.2% of patients having grade I, grade II, and grade III hypertension, respectively. From 2014 to 2020, prevalence rate of pre-dialysis hypertension and absolute values of pre-dialysis SBP were higher in dialysis patients with diabetes than in those without diabetes across all age groups and sexes. Younger patients with diabetes or those on anti-hypertensive medication exhibited an SBP of approximately 160 mm Hg. Cerebrovascular death in patients with diabetes was associated with a higher rate of pre-dialysis hypertension than that in those without diabetes, and there was a significant difference in the prevalence of grade III hypertension between the two groups. In conclusion, the mean pre-dialysis SBP among patients undergoing dialysis remained high, and younger patients with diabetes or those receiving anti-hypertensive medications had poor blood pressure control. Optimal blood pressure management may be necessary to reduce the risk of cardiovascular mortality.