Role of systolic blood pressure in determining prognosis of hemodialyzed patients

Tomita, Jun; Kimura, Genjiro; Inoue, Takuya; Inenaga, Takashi; Sanai, Toru; Kawano, Yuhei; Nakamura, Satoko; Baba, Shunroku; Matsuoka, Hiroaki; Omae, Teruo

doi:10.1016/0272-6386(95)90101-9

Cited by 119 publications

(67 citation statements)

References 15 publications

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“…7 Irrespective of the cause of ESRD, survival is better in normotensive than hypertensive patients with ESRD. Renal failureassociated hypertension occurs in patients of all volume states and commonly accompanies advancing renal failure before dialysis dependence, when total body water is near normal.…”

Section: Discussionmentioning

confidence: 99%

“…A number of patients with ESRD have difficult-to-control hypertension without clinical evidence of volume overload. [4][5][6][7] The contention that refractory hypertension in ESRD is not solely caused by fluid accumulation is supported by clinical experience with patients undergoing PD, who are less often fluid overloaded but commonly require antihypertensive therapy. In the present study, 15 of 17 HD patients in the NO x production study were receiving antihypertensive medications despite which the pre-HD systolic BP was elevated versus controls.…”

Section: Discussionmentioning

confidence: 99%

“…Chronic experimental NOS inhibition in animals produces hypertension, and NOS may be defective in some individuals with primary and secondary hypertension. 3 Hypertension is particularly prevalent in hemodialysis (HD) patients with end-stage renal disease (ESRD), [4][5][6][7] and there are valid reasons to suspect NO deficiency might occur and contribute to the hypertension in this population. We previously reported that patients with ESRD undergoing peritoneal dialysis (PD) produce less NO, indicated by the removal rate of the stable inert oxidation products of NO (NO 2 + NO 3 [NO x ]) in peritoneal dialysate plus urine.…”

Section: Index Wordsmentioning

confidence: 99%

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Indices of activity of the nitric oxide system in hemodialysis patients

Schmidt

Domico

Samsell

et al. 1999

American Journal of Kidney Diseases

102

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Arginine deficiency and/or increased levels of circulating nitric oxide (NO) synthesis (NOS) inhibitors can cause reduced NOS, which may contribute to hypertension in patients with end-stage renal disease (ESRD). To test these hypotheses, NO oxidation products (NO 2 + NO 3 = NO x ) and cyclic guanosine monophosphate (cGMP), the vasodilatory second messenger of NO, were measured in the blood, urine, and dialysate effluent of hemodialysis (HD) patients and compared with the blood and urine of healthy subjects. The subjects ate a controlled low-nitrate diet (∼330 μmol/d) for 48 hours before and during blood, dialysis effluent, and 24-hour urine collection. NO x output was significantly reduced in HD patients versus controls (552 ± 51 v 824 ± 96 μmol/24 h; P < 0.001), whereas cGMP output was not low versus controls. Plasma arginine level was normal and plasma levels of citrulline and the endogenous NOS inhibitor, asymmetric dimethylarginine (ADMA), were markedly elevated in patients with ESRD versus controls. Systolic blood pressure was greater in HD patients compared with controls despite concurrent antihypertensive therapy in most patients with ESRD. These studies suggest NO production is low in patients with ESRD undergoing HD, possibly because of the increased ratio of plasma ADMA to arginine. Index WordsEnd-stage renal disease; hypertension; arginine; cyclic guanosine monophosphate (cGMP); endogenous nitric oxide synthases (NOS) inhibitors Nitric oxide (NO) is a potent vasodilator made from L-arginine by the enzymatic action of several widely distributed nitric oxide synthases (NOSs). The constitutively expressed, vascular endothelial and brain-type NOSs have major roles in the physiological control of vascular tone and kidney function, and many of these actions are mediated by cyclic guanosine monophosphate (cGMP). 1,2 NO deficiency can be produced experimentally by the administration of substituted L-arginine analogues that function as competitive inhibitors of NOS. Chronic experimental NOS inhibition in animals produces hypertension, and NOS may be defective in some individuals with primary and secondary hypertension. 3 Hypertension is particularly prevalent in hemodialysis (HD) patients with end-stage renal disease (ESRD), 4-7 and there are valid reasons to suspect NO deficiency might occur and contribute to the hypertension in this population. We previously reported that patients with ESRD undergoing peritoneal dialysis (PD) produce less NO, indicated by the removal rate of the stable inert oxidation products of NO (NO 2 In addition, the plasma levels of naturally occurring compounds that inhibit the L-arginine-NO pathway accumulate in patients with ESRD. For example, plasma levels of asymmetric dimethylarginine (ADMA) increase in HD patients, possibly to concentrations that inhibit NOS, although this remains controversial. 9,10 This, together with plasma arginine levels in the low-normal range, 9,11 means the ratio of plasma levels of endogenous NOS inhibitors to Larginine is high in patients wit...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Index Wordsmentioning

confidence: 99%

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Indices of activity of the nitric oxide system in hemodialysis patients

Schmidt

Domico

Samsell

et al. 1999

American Journal of Kidney Diseases

102

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“…Some studies suggest an association of high BP with strokes, 165,166 cerebral atrophy, 167 cardiovascular events, 168 complex cardiac arrhythmias, 169 the development of congestive heart failure, 161 and all-cause mortality. 170 Other studies suggest that low BP measured either predialysis or postdialysis is associated with increased mortality. 164,[171][172][173] This association of low BP and mortality is further magnified when BP is considered as a time-dependent covariate.…”

Section: Relationship Of Bp and Mortalitymentioning

confidence: 99%

Assessment and Management of Hypertension in Patients on Dialysis

Agarwal

Flynn

Pogue

et al. 2014

Journal of the American Society of Nephrology

147

154

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Hypertension is common, difficult to diagnose, and poorly controlled among patients with ESRD. However, controversy surrounds the diagnosis and treatment of hypertension. Here, we describe the diagnosis, epidemiology, and management of hypertension in dialysis patients, and examine the data sparking debate over appropriate methods for diagnosing and treating hypertension. Furthermore, we consider the issues uniquely related to hypertension in pediatric dialysis patients. Future clinical trials designed to clarify the controversial results discussed here should lead to the implementation of diagnostic and therapeutic techniques that improve long-term cardiovascular outcomes in patients with ESRD. Hypertension is common among patients with ESRD. In this review, we discuss the diagnosis, epidemiology, and management of hypertension among dialysis patients. We also review areas of existing controversies and briefly discuss the issue of hypertension in pediatric dialysis patients. EPIDEMIOLOGYThe prevalence, treatment, and control of hypertension among people on hemodialysis (HD) have used varying definitions to diagnose hypertension. The epidemiology differs based on how BP is measured: either before and after dialysis or using ambulatory BP recordings. Epidemiology with Routine BP MeasurementsThe prevalence of hypertension (defined as 1-week average predialysis systolic BP [SBP] measurements .150 mmHg or diastolic BP [DBP].85 mmHg or the use of antihypertensive medications) was 86% among 2535 clinically stable adult HD patients participating in a multicenter trial. 1 Among hypertensive patients, 12% did not receive antihypertensive drugs, 58% were treated but not controlled, and only 30% were controlled. The use of antihypertensive drugs has been reported to vary from 59% to 83%. [2][3][4][5] Furthermore, even among children on long-term HD, similar findings have been reported. 6 Several studies have confirmed greater antihypertensive drug use to be associated with poorer control. 7,8 It should be noted that antihypertensive drug use per se do not lead to worse BP control; in the absence of adequate volume control, increasing antihypertensive drug use may simply reflect difficult-to-control BP. Epidemiology Using Ambulatory BP MeasurementsThe prevalence of hypertension (defined by either a 44-hour interdialytic ambulatory BP of $135/85 mmHg or the prescription of any antihypertensive agent) was 86% among 369 chronic HD patients. 8 Although hypertension was being treated with antihypertensive drugs in 89% of patients, it was adequately controlled only in 38%. The independent determinants of poor control were the use of antihypertensive drugs and an expanded extracellular volume state. If patients were volume overloaded, nearly 80% became hypertensive when medications were Published online ahead of print. Publication date available at www.jasn.org.

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“…H ypertension plays an important role in the development of cardiovascular disorders in hemodialysis (HD) patients as well as patients with essential hypertensive (1,2). A number of observational cohort studies have reported U-shaped or reverse-J relationships between conventional BP measures (systolic [SBP], diastolic [DBP], and mean arterial) and mortality in patients who undergo HD (3)(4)(5)(6); however, it has also been reported that no significant difference has been found between the survival rates of 168 normotensive and 202 hypertensive HD patients (7).…”

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confidence: 99%

Weekly Averaged Blood Pressure Is More Important than a Single-Point Blood Pressure Measurement in the Risk Stratification of Dialysis Patients

Moriya

Oka

Maesato

et al. 2008

Clinical Journal of the American Society of Nephrology

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Background and objectives: With regard to monitoring blood pressure in hemodialysis patients, it is important to define clearly the time point at which the blood pressure is measured, because the blood pressure of hemodialysis patients varies with each hemodialysis session as a result of loss of excess fluid.Design, setting, participants, & measurements: Using weekly averaged blood pressure, 96 hemodialysis patients were studied prospectively for 35 mo. All patients were followed up for cardiovascular events or death from all causes.Results: Pulse weekly averaged blood pressure and age at enrollment were significantly higher and parathyroid hormone level was significantly lower in patients with cardiovascular events compared with those without cardiovascular events; however, none of the components of pre-or postdialysis blood pressure was significantly different between patients with and without cardiovascular events. Pulse weekly averaged blood pressure, prepulse pressure, age, and human atrial natriuretic peptide were significantly higher in patients who died than in survivors. Kaplan-Meier method with a log-rank test demonstrated that survival free rate from cardiovascular events and that of all-cause mortality in patients with pulse weekly averaged blood pressure >70 mmHg were significantly lower than those in the remaining patients.Conclusions: One-point measurement of blood pressure is insufficient to evaluate hypertension and prognosis of hemodialysis patients, and weekly averaged blood pressure is a useful marker because of averaging fluctuations of blood pressure during 1 wk. Among components of weekly averaged blood pressure, pulse weekly averaged blood pressure could be a good prognostic marker of the incidence of both cardiovascular events and all-cause mortality in hemodialysis patients.

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Role of systolic blood pressure in determining prognosis of hemodialyzed patients

Cited by 119 publications

References 15 publications

Indices of activity of the nitric oxide system in hemodialysis patients

Indices of activity of the nitric oxide system in hemodialysis patients

Assessment and Management of Hypertension in Patients on Dialysis

Weekly Averaged Blood Pressure Is More Important than a Single-Point Blood Pressure Measurement in the Risk Stratification of Dialysis Patients

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