Low diastolic blood pressure, hypoalbuminemia, and risk of death in a cohort of chronic hemodialysis patients

Iseki, Kunitoshi; Miyasato, Fujihiko; Tokuyama, Kiyoyuki; Nishime, Keizo; Uehara, Hajime; Shiohira, Yoshiki; Saito, Hiroshi; Yoshihara, Kunio; Yoshi, Shinichiro; Toma, Shigeki; Kowatari, Teruo; Wake, Toru; Oura, Takashi; Fukiyama, Koshiro

doi:10.1038/ki.1997.165

Cited by 153 publications

(106 citation statements)

References 31 publications

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“…Hypertension, however, was associated with a 26% decreased risk of mortality (P ϭ 0.0001). This finding is consistent with other reports, not fully understood, that high predialysis BP is protective in ESRD patients (13)(14)(15)(16). LVH was associated with an increased risk of mortality in univariate analysis (RR ϭ 1.17) but a decreased risk in multivariate analysis (RR ϭ 0.92).…”

Section: Discussionsupporting

confidence: 92%

Association of Comorbid Conditions and Mortality in Hemodialysis Patients in Europe, Japan, and the United States

Goodkin

Bragg‐Gresham²,

Koenig

et al. 2003

Journal of the American Society of Nephrology

690

499

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Abstract. Mortality rates among hemodialysis patients vary greatly across regions. Representative databases containing extensive profiles of patient characteristics and outcomes are lacking. The Dialysis Outcomes and Practice Patterns Study (DOPPS) is a prospective, observational study of representative samples of hemodialysis patients in France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States (US) that captures extensive data relating to patient characteristics, prescriptions, laboratory values, practice patterns, and outcomes. This report describes the case-mix features and mortality among 16,720 patients followed up to 5 yr. The crude 1-yr mortality rates were 6.6% in Japan, 15.6% in Europe, and 21.7% in the US. After adjusting for age, gender, race, and 25 comorbid conditions, the relative risk (RR) of mortality was 2.84 (P Ͻ 0.0001) for Europe compared with Japan (reference group) and was 3.78 (P Ͻ 0.0001) for the US compared with Japan. The adjusted RR of mortality for the US versus Europe was 1.33 (P Ͻ 0.0001). For most comorbid diseases, prevalence was highest in the US, where the mean age (60.5 Ϯ 15.5 yr) was also highest. Older age and comorbidities were associated with increased risk of death (except for hypertension, which carried a multivariate RR of mortality of 0.74 [P Ͻ 0.0001]). Variability in demographic and comorbid conditions (as identified by dialysis facilities) explains only part of the differences in mortality between dialysis centers, both for comparisons made across continents and within the US. Adjustments for the observed variability will allow study of association between practice patterns and outcomes.Outcomes among dialysis patients differ considerably between and within countries. One of the most concerning differences is the varying mortality rate across countries with large populations of dialysis patients. Held et al. (1) reported the mortality risk for the renal replacement population in the United States (US), adjusted for age and diabetes mellitus, to be 15% higher than the European risk and 33% higher than the Japanese risk.

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Section: Discussionsupporting

confidence: 92%

Association of Comorbid Conditions and Mortality in Hemodialysis Patients in Europe, Japan, and the United States

Goodkin

Bragg‐Gresham²,

Koenig

et al. 2003

Journal of the American Society of Nephrology

690

499

View full text Add to dashboard Cite

show abstract

“…Results from the ongoing randomized, placebo-controlled National Institutes of Health cooperative FAVORIT (Folic Acid for Vascular Outcome Reduction in Transplantation) trial will help to resolve this issue more definitively. Although we are not certain why a higher diastolic pressure was associated with fewer cardiovascular events, a lower diastolic BP may simply be a marker of cardiovascular dysfunction (and subsequent events), as it seems to be in chronic hemodialysis patients (27).…”

Section: Resultsmentioning

confidence: 85%

Total Plasma Homocysteine and Arteriosclerotic Outcomes in Type 2 Diabetes with Nephropathy

Friedman¹,

Hunsicker

Selhub

et al. 2005

Journal of the American Society of Nephrology

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Total serum homocysteine (tHcy) has been shown to predict de novo and recurrent cardiovascular events in many studies. However, results in diabetic populations with minimal nephropathy are mixed. The independent relationship between tHcy and arteriosclerotic outcomes and congestive heart failure (CHF) events in a population with high cardiovascular risk and diabetic nephropathy was examined. A total of 1575 individuals were enrolled in the international Irbesartan Diabetic Nephropathy Trial (IDNT) and followed for 2.6 yr. All participants had baseline diabetic nephropathy, overt proteinuria, and hypertension and were recruited between 1996 and 1999. A total of 492 total arteriosclerotic outcomes (primary outcome) and 317 CHF events (secondary outcome) were tallied. Established cardiovascular risk factors were highly prevalent, as were high tHcy levels (quintiles [M]: first 4.5 to 11; second >11 to 13; third >13 to 15; fourth >15 to 19; fifth >19). No association between tHcy and arteriosclerotic outcomes was observed in a univariate model or after adjustment for study randomization and established cardiovascular risk factors. The strongest outcome predictor was the presence of baseline cardiovascular disease, followed by an inverse relationship to diastolic BP. The significant univariate association between tHcy and CHF events disappeared when serum creatinine alone was added to the model. These findings question the utility of tHcy in predicting de novo or recurrent cardiovascular events in individuals with diabetic nephropathy. Further studies are needed to confirm whether these negative results apply to other populations with heavy cardiovascular risk burdens. Previous positive findings can potentially be explained through tHcy's role as a sensitive surrogate marker for kidney disease, itself a recognized cardiovascular risk factor.

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“…Previous observational studies in the dialysis population and in patients with less severe kidney disease have found that both higher and lower SBP and DBP were associated with a higher risk of death and CVD (9,(14)(15)(16)(17)(18)(19). A recent study by Kovesdy et al examined .600,000 veterans with CKD and found that patients in whom both SBP and DBP were very high or very low had the highest mortality rates (3).…”

Section: Discussionmentioning

confidence: 99%

Association of BP with Death, Cardiovascular Events, and Progression to Chronic Dialysis in Patients with Advanced Kidney Disease

Palit¹,

Chonchol²,

Cheung³

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objective The optimal BP target to reduce adverse clinical outcomes in patients with CKD is unclear. This study examined the relationship between BP and death, cardiovascular events (CVEs), and kidney disease progression in patients with advanced kidney disease.Design, setting, participants, & measurements The relationship of systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) with death, CVE, and progression to long-term dialysis was examined in 1099 patients with advanced CKD (eGFR#30 ml/min per 1.7 3m 2 ; not receiving dialysis) who participated in the Homocysteine in Kidney and ESRD study. That study enrolled participants from 2001 to 2003. Cox proportional hazard models were used to examine the association between BP and adverse outcomes.Results The mean6SD baseline eGFR was 1867 ml/min per 1.73 m 2 . During a median follow-up of 2.9 years, 453 patients died, 215 had a CVE, and 615 initiated long-term dialysis. After adjustment for demographic characteristics and confounders, SBP, DBP, and PP were not associated with a higher risk of death. SBP and DBP were also not associated with CVE. The highest quartile of PP was associated with a substantial higher risk of CVE compared with the lowest quartile (hazard ratio [HR], 1.67; 95% confidence interval [95% CI], 1.10 to 2.52). The highest quartiles of SBP (HR, 1.28; 95% CI, 1.01 to 1.61) and DBP (HR, 1.36; 95% CI, 1.07 to 1.73), but not PP, were associated with a higher risk of progression to long-term dialysis compared with the lowest quartile.Conclusions In patients with advanced kidney disease not undergoing dialysis, higher PP was strongly associated with CVE whereas higher SBP and DBP were associated with progression to long-term dialysis. These results suggest that SBP and DBP should not be the only factors considered in determining antihypertensive therapy; elevated PP should also be considered.

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Low diastolic blood pressure, hypoalbuminemia, and risk of death in a cohort of chronic hemodialysis patients

Cited by 153 publications

References 31 publications

Association of Comorbid Conditions and Mortality in Hemodialysis Patients in Europe, Japan, and the United States

Association of Comorbid Conditions and Mortality in Hemodialysis Patients in Europe, Japan, and the United States

Total Plasma Homocysteine and Arteriosclerotic Outcomes in Type 2 Diabetes with Nephropathy

Association of BP with Death, Cardiovascular Events, and Progression to Chronic Dialysis in Patients with Advanced Kidney Disease

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