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Ambulatory blood pressure (BP) control is worse in men than women with chronic kidney disease or kidney transplantation. So far, no study investigated possible sex differences in the prevalence, control, and phenotypes of BP according to predialysis and 48-h ambulatory blood pressure monitoring (ABPM) in hemodialysis patients. Further, no study has evaluated the diagnostic accuracy of predialysis BP in male and female hemodialysis patients.One hundred and twenty-nine male and 91 female hemodialysis patients that underwent 48-h ABPM were included in this analysis. Hypertension was defined as: (1) predialysis SBP ≥140 or DBP ≥90 mmHg or use of antihypertensive agents, (2) 48-h SBP ≥130 or DBP ≥80 mmHg or use of antihypertensive agents.Predialysis SBP did not differ between groups, while DBP was marginally higher in men. 48-h SBP (137.2 ± 17.4 vs. 132.2 ± 19.2 mmHg, P = 0.045), DBP (81.9 ± 12.1 vs. 75.9 ± 11.7 mmHg, P 0.001) and daytime SBP/DBP were higher in men. The prevalence of hypertension was not different between groups with the use of predialysis BP or 48-h ABPM (92.2% vs. 89%, P = 0.411). However, concordant lack of control was more frequent in men than women (65.3% vs. 49.4%, P = 0.023). The prevalence of white-coat and masked hypertension did not differ between groups; the misclassification rate with the use of predialysis BP was marginally higher in women. In both sexes, predialysis BP showed low accuracy and poor agreement with ABPM for diagnosing ambulatory hypertension [area-under-the-curve in receiver-operating-curve analyses (SBP/DBP): men, 0.681/0.802, women: 0.586/0.707].Ambulatory BP levels are higher in male than female hemodialysis patients. Although hypertension prevalence is similar between sexes, men have worse rates of control. The diagnostic accuracy of predialysis BP was equally poor in men and women.

BACKGROUND AND AIMS Assessment of dry-weight among patients on haemodialysis is challenging in the absence of reliable markers to define overhydration (OH) [1, 2]. This study aimed to explore the value of two simple clinical signs, the presence of pedal oedema and crackles at pulmonary auscultation, in diagnosing hypervolemia, using the bioimpendence spectroscopy as a more objective method. METHOD In a cohort of 107 asymptomatic dialysis patients, the volume status was assessed with physical examination and bioimpedance spectroscopy shortly before the mid-week dialysis session [3]. Patients were also asked to perform home blood pressure (BP) monitoring with a validated, automatic device (HEM-705, Omron, Healthcare) [4] for 1 week in order to determine their BP control status. RESULTS Patients within the high tertile of pre-dialysis OH had longer dialysis vintage, lower serum albumin and higher home systolic BP, despite the more aggressive treatment with a higher average number of antihypertensives daily. In receiver-operating-characteristic (ROC) curve analysis, pedal oedema [area under curve (AUC): 0.534, 95% confidence interval (95% CI) 0.416–0.651] and pulmonary crackles (AUC: 0.551; 95% CI 0.432–0.671) had limited accuracy in the diagnosis of pre-dialysis OH > 2.2 L. The agreement of pedal oedema (Cohen's k-coefficient: 0.065) and pulmonary crackles (Cohen's k-coefficient: 0.122) with bioimpedance spectroscopy in the detection of hypervolemia was poor. In multivariate linear regression analysis, longer dialysis vintage (β: 0.306; P CONCLUSION This diagnostic-test study showed that among asymptomatic hemodialysis patients, pedal oedema and pulmonary crackles in physical examination had limited discriminatory power in the detection of hypevolemia, as assessed more objectively with the method of bioimpedance spectroscopy.

BACKGROUND AND AIMS Prospective cohort studies have shown that among patients on haemodialysis, hyperkalaemia is strongly associated with excess risk for cardiovascular-related hospitalizations and sudden cardiac death [1–4]. However, the actual burden of hyperkalaemia, the rates of its recurrence and seasonality in its variation still remain unclear. METHOD Between June 2020 and May 2021, 1786 mid-week predialysis serum potassium (sK) measurements were retrospectively recorded from 149 patients receiving thrice-weekly haemodialysis in a single-centre in Thessaloniki, Greece. The prevalence, recurrence and seasonal variation of hyperkalaemia were assessed using three prespecified sK thresholds (≥5.1, ≥5.5 and ≥ 6.0 mmol/L). RESULTS At baseline (June 2020), 60.4%, 42.2% and 13.4% of patients had sK levels ≥ 5.1, ≥5.5 and ≥ 6.0 mmol/L, respectively. At any time-point during the 1-year-long follow-up, 85.2%, 69.8% and 38.9% of patients experienced at least 1 hyperkalaemic episode at the sK threshold of ≥ 5.1, ≥5.5 and ≥ 6.0 mmol/L, respectively. Of the 104 patients experiencing an initial sK elevation ≥ 5.5 mmol/L, hyperkalaemia at the same threshold reoccurred in 60.6% at month-1, in 47.1% at month-2 and in 46.1% at month-3 of follow-up. Seasonal variation was also observed, with the prevalence of hyperkalaemia to be significantly higher in summer. In multivariate logistic regression analysis, shorter delivered haemodialysis CONCLUSION The present study shows that among patients receiving conventional thrice-weekly haemodialysis, the rates of hyperkalaemia prevalence and recurrence are very high, reflecting the large unmet need to identify more effective potassium-lowering therapeutic interventions in this high-risk population.

BACKGROUND AND AIMS In contrast with pre- and post-dialysis blood pressure (BP), intradialytic and home BP measurements are accurate metrics of ambulatory BP load in hemodialysis patients. This study assessed the agreement of peridialytic, intradialytic and scheduled interdialytic recordings with 44-h interdialytic BP in a distinct hemodialysis population, patients with intradialytic-hypertension (IDH). METHOD 45 patients with IDH (defined as: SBP rise ≥ 10 mmHg from pre- to post-dialysis and post-dialysis SBP ≥ 150 mmHg) with valid 48-h ABPM and 197 without IDH were included in this analysis. With 44-h BP used as reference method, we tested the accuracy of the following BP metrics: Pre- and post-dialysis, intradialytic, intradialytic plus pre/post-dialysis readings and scheduled interdialytic BP (out-of-dialysis day: readings at 8:00 am, 8:00 pm or their average). RESULTS In patients with IDH, peri-dialytic and intradialytic BP metrics showed at best moderate correlations, while averaged-interdialytic-SBP/DBP exhibited strong correlation (r = 0.882/r = 0.855) with 44-h SBP/DBP. Bland-Altman plots showed large between-method difference for peri- and intradialytic BP, but only + 0.7 mmHg between-method difference and good 95% limits-of-agreement for averaged-interdialytic-SBP. The sensitivity/specificity and κ-statistic for diagnosing 44-h SBP ≥ 130 mmHg were low for pre-dialysis (72.5%/40.0%, κ-statistic = 0.074) and post-dialysis (90.0%/0.0%, κ-statistic = −0.110), intradialytic (85.0%/40.0%, κ-statistic = 0.198) and intradialytic plus pre/post-dialysis SBP (85.0%/20.0%, κ-statistic = 0.043). Averaged-interdialytic-SBP showed high values of sensitivity/specificity (97.5%/80.0%) and strong agreement (κ-statistic = 0.775). In ROC-analyses, the peri- and intradialytic BP metrics showed bad performance with low Area-Under-the-Curve values; scheduled interdialytic SBP/DBP had the largest AUC (0.967/0.951), along with the highest sensitivity(90.0%/88.0%) and specificity(100.0%/90.0%) for detecting elevated 44-h BP. CONCLUSION In patients with IDH, averaged-scheduled-interdialytic but not pre- and post-dialysis, nor intradialytic BP recordings show reasonable agreement with ambulatory BP. Interdialytic BP recordings only could be used for hypertension diagnosis and management in these subjects.

BACKGROUND AND AIMS Ambulatory blood pressure (BP) control is worse in men than in women with chronic kidney disease (CKD), and this may partially explain the faster CKD progression in men. The aim of this study is to investigate possible sex-differences in ambulatory BP levels, BP trajectories and BP variability (BPV) in hemodialysis patients. METHOD 129 male and 91 female hemodialysis patients that underwent 48-h ABPM with Mobil-O-Graph-NG were included in this analysis. Ambulatory BP levels over the 2-day interdialytic interval (including two daytime and two nighttime periods) were recorded. We calculated the standard deviation (SD), weighted SD (wSD), coefficient of variation (CV) and average real variability (ARV) of BP with validated formulas. RESULTS Age, dialysis vintage, antihypertensive treatment and history of major comorbidities did not differ between men and women. Pre-dialysis SBP levels did not differ between men and women (145.1 ± 22.7 versus 145.9 ± 25.7 mmHg, P = 0.808), but DBP was marginally higher in men (87.6 ± 14.0 versus 84.0 ± 13.7 mmHg, P =0.055). About 48-h SBP/DBP (137.2 ± 17.4/81.9 ± 12.1 mmHg versus 132.2 ± 19.2/75.9 ± 11.7 mmHg, P = 0.045/ CONCLUSION Ambulatory BP levels and trajectories, as well as DBP variability indices are higher in men than women hemodialysis patients. This worse ambulatory BP profile in male compared to female patients may impact on the incidence of cardiovascular events.

BACKGROUND AND AIMS Patients with intradialytic hypertension (IDH) have higher mean 44-h ambulatory blood pressure (BP) levels than patients without the phenomenon. IDH is associated with an increased risk of cardiovascular and all-cause mortality. Whether the excess risk for mortality in patients with IDH depends on the BP rise during dialysis per se or on elevated 44-h ambulatory BP is not known. This is the first study evaluating the association of IDH with cardiovascular events and all-cause mortality before and after adjustment for ambulatory BP and other cardiovascular risk factors. METHOD A total of 242 haemodialysis patients underwent 48-h ABPM with Mobil-O-Graph-NG and were followed for a median of 45.7 months. IDH was defined as: SBP rise ≥ 10 mmHg from pre- to post-dialysis and post-dialysis SBP ≥ 150 mmHg. The primary end-point was all-cause mortality; the secondary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary or peripheral revascularization procedures. RESULTS During follow-up, a total of 122 patients died; 69 due to cardiovascular causes. Cumulative freedom from both the primary and secondary endpoints was significantly lower for patients with IDH (log rank-P = 0.048/0.022, respectively). The risk for all-cause mortality was significantly higher for patients with IDH [HR = 1.566, 95% confidence interval (95% CI) (1.001, 2.450)]; similarly, the risk for the combined cardiovascular endpoint was higher for these individuals [HR = 1.675, 95% CI (1.071, 2.620)]. The observed associations attenuated after adjustment for 44-h SBP [all-cause mortality: HR = 1.529, 95% CI (0.952, 2.457)] and combined cardiovascular endpoint: HR = 1.388 95% CI (0.866, 2.225). After additional adjustment for age, interdialytic weight gain, dialysis vintage, 44-h pulse wave velocity, history of coronary artery disease, diabetes mellitus and heart failure the respective HRs were 1.409 [95% CI (0.851, 2.332)] and 1.435 [95% CI (0.879, 2.343)]. CONCLUSION Patients with IDH presented higher risk for death and cardiovascular outcomes. Sustained high BP levels during the 44-h interdialytic period and not only intradialytic BP rise per se may be participating in the excess risk of this condition.

BACKGROUND AND AIMS Increased arterial stiffness is suggested to be involved in the pathogenesis of intradialytic hypertension (IDH). Ambulatory pulse wave velocity (PWV) is an independent predictor for all-cause-mortality in hemodialysis patients and its prognostic power is better than office PWV. This is the first study comparing ambulatory central blood pressure (BP) and arterial stiffness parameters between patients with and without IDH. METHOD This study examined 45 patients with IDH (defined as: SBP rise ≥ 10 mmHg from pre- to post-dialysis and post-dialysis SBP ≥ 150 mmHg) in comparison 197 without IDH. All participants underwent 48-h ABPM with the Mobil-O-Graph-NG device; parameters of central hemodynamics [central systolic (cSBP) and diastolic BP (cDBP), pulse pressure (PP)], wave reflection [augmentation index (AIx) and pressure (AP)] and PWV were estimated. RESULTS Age, dialysis vintage, interdialytic weight gain and prevalence of major comorbidities did not differ between the two study groups. Patients with IDH had higher 44-h cSBP (131.6 ± 16.7 versus 119.3 ± 15.6, P CONCLUSION Patients with IDH have higher ambulatory central BP and increased arterial stiffness, as indicated by higher ambulatory cPP and PWV. Increased arterial stiffness could be a prominent factor associated with the high burden of cardiovascular disease in this population.

Rationale & Objective Left ventricular (LV) hypertrophy and dysfunction are associated with adverse outcomes in hemodialysis patients. Hypertension and hypervolemia play important roles in these cardiac abnormalities. We report on the prespecified secondary outcome, echocardiographic indexes of LV function, from a previously reported study of the effect of lung ultrasound (US)-guided dry weight reduction on systolic blood pressure. Study Design Single-blind randomized trial. Settings & Participants 71 clinically euvolemic hypertensive hemodialysis patients in Greece and Slovenia. Intervention The active intervention group's (n=35) volume removal was guided by the total number of lung US B-lines observed every week before a midweek dialysis session. The usual-care group (n=36) was treated using standard-of-care processes that did not include acquisition of US data. Outcomes 2-dimensional and tissue Doppler echocardiographic indexes at baseline and study end (8 weeks) that evaluated left and right heart chamber sizes, as well as systolic and diastolic function. Results Overall, 19 (54%) patients in the active intervention and 5 (14%) in the usual-care group had ultrafiltration intensification (P Limitations Exploratory study; small sample size. Conclusions A US-guided strategy for dry weight reduction is associated with decreased cardiac chamber dimensions and LV filling pressure, but no difference in systolic performance compared with usual care in hypertensive hemodialysis patients. Funding European Renal Association–European Dialysis and Transplant Association. Trial Registration Registered at ClinicalTrials.gov with study number NCT03058874.

Purpose In contrast to peridialytic blood pressure (BP), intradialytic and home BP measurements are accurate metrics of ambulatory BP load in hemodialysis patients. This study assessed the agreement of peridialytic, intradialytic, and scheduled interdialytic recordings with 44-h BP in a distinct hemodialysis population, patients with intradialytic hypertension (IDH). Methods This study included 45 IDH patients with valid 48-h ABPM and 197 without IDH. With 44-h BP used as reference method, we tested the accuracy of the following BP metrics: Pre- and post-dialysis, mean and median intradialytic, mean intradialytic plus pre/post-dialysis, and scheduled interdialytic BP (out-of-dialysis day: mean of 8:00am/8:00 pm readings). Results In IDH patients, peridialytic and intradialytic BP metrics showed at best moderate correlations, while averaged interdialytic SBP/DBP exhibited strong correlation (r = 0.882/r = 0.855) with 44-h SBP/DBP. Bland–Altman plots showed large between-method-difference for peri- and intradialytic-BP, but only + 0.7 mmHg between-method difference and good 95% limits of agreement for averaged interdialytic SBP. The sensitivity/specificity and κ-statistic for diagnosing 44-h SBP ≥ 130 mmHg were low for pre-dialysis (72.5/40.0%, κ-statistic = 0.074) and post-dialysis (90.0/0.0%, κ-statistic = − 0.110), mean intradialytic (85.0/40.0%, κ-statistic = 0.198), median intradialytic (85.0/60.0%, κ-statistic = 0.333), and intradialytic plus pre/post-dialysis SBP (85.0/20.0%, κ-statistic = 0.043). Averaged interdialytic SBP showed high sensitivity/specificity (97.5/80.0%) and strong agreement (κ-statistic = 0.775). In ROC analyses, scheduled interdialytic SBP/DBP had the highest AUC (0.967/0.951), sensitivity (90.0/88.0%), and specificity (100.0/90.0%). Conclusion In IDH patients, only averaged scheduled interdialytic but not pre- and post-dialysis, nor intradialytic BP recordings show reasonable agreement with ABPM. Interdialytic BP recordings only could be used for hypertension diagnosis and management in these subjects.

Ambulatory-BP-monitoring (ABPM) is recommended for hypertension diagnosis and management in hemodialysis patients due to its strong association with outcomes. Intradialytic and scheduled interdialytic BP recordings show agreement with ambulatory BP. This study assesses in parallel the association of pre-dialysis, intradialytic, scheduled interdialytic and ambulatory BP recordings with cardiovascular events.We prospectively followed 242 hemodialysis patients with valid 48-h ABPMs for a median of 45.7 months to examine the association of pre-dialysis, intradialytic, intradialytic plus pre/post-dialysis readings, scheduled interdialytic BP, and 44-h ambulatory BP with outcomes. The primary end-point was a composite one, composed of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary revascularization procedure or peripheral revascularization procedure.Cumulative freedom from the primary end-point was significantly lower with increasing 44-h SBP (group 1, 120 mmHg, 64.2%; group 2, ≥ 120 to 130 mmHg 60.4%, group 3, ≥ 130 to 140 mmHg 45.3%; group 4, ≥ 140 mmHg 45.5%; logrank-p = 0.016). Similar were the results for intradialytic (logrank-p = 0.039), intradialytic plus pre/post-dialysis (logrank-p = 0.044), and scheduled interdialytic SBP (logrank-p = 0.030), but not for pre-dialysis SBP (logrank-p = 0.570). Considering group 1 as the reference group, the hazard ratios of the primary end-point showed a gradual increase with higher BP levels with all BP metrics, except pre-dialysis SBP. This pattern was confirmed in adjusted analyses. An inverse association of DBP levels with outcomes was shown with all BP metrics, which was no longer evident in adjusted analyses.Averaged intradialytic and scheduled home BP measurements (but not pre-dialysis readings) display similar prognostic associations with 44-h ambulatory BP in hemodialysis patients and represent valid metrics for hypertension management in these individuals.

Background and Aims Hypertension is highly prevalent in hemodialysis patients. Current recommendations suggest the use of ambulatory-BP-monitoring (ABPM) as the gold-standard for hypertension diagnosis and management in these subjects. This study assessed the accuracy of peridialytic, intradialytic and scheduled interdialytic recordings in diagnosing high 44-h interdialytic BP. Method A total of 242 hemodialysis patients that underwent valid 48-h ABPM were included in the analysis. We used ambulatory BP as reference standard and tested the accuracy of the following BP metrics: Pre- and post-dialysis, Intradialytic, Intradialytic plus pre/post-dialysis readings and Scheduled interdialytic BP (out-of-dialysis day: readings at 8:00 am, 8:00 pm or their average). Results 44-h SBP/DBP levels had significant differences with and pre- or post-dialysis BP, but no or minor differences with any of the other BP metrics. 44-h SBP and DBP correlated strongly with Intradialytic (r=0.713/0.753, p Conclusion In contrast to pre- and post-dialysis BP, the average of intradialytic, intradialytic plus pre/post-dialysis or scheduled interdialytic BP recordings show reasonable agreement with ambulatory BP and may be used for hypertension diagnosis and management in hemodialysis.

Background and Aims Ambulatory-BP-monitoring (ABPM) is recommended for hypertension diagnosis and management in hemodialysis subjects due to high accuracy and strong associations with outcomes. The agreement and prediction of averaged intradialytic BP readings and home BP readings with ABPM and clinical outcomes is not known. This study assesses in parallel the association of pre-dialysis, intradialytic, scheduled interdialytic and ambulatory BP recordings with cardiovascular outcomes and mortality in this population. Method We prospectively followed for 49.1±25.6 months 242 hemodialysis patients with valid 48-hour ABPMs to examine the association of pre-dialysis, intradialytic, intradialytic plus pre/post-dialysis readings, scheduled interdialytic BP (the average of out-of-dialysis day readings at 8:00 am and 8:00 pm) and 44-hour ambulatory BP with outcomes. The primary end-point was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary revascularization procedure or peripheral revascularization procedure. Results Cumulative freedom from the primary end-point was significantly lower with increasing 44-hour SBP (group 1, Conclusion Averaged intradialytic and scheduled home BP measurements (but not pre-dialysis readings) display similar patterns of prognostic associations with 44-hour ambulatory BP in hemodialysis patients and represent valid metrics for hypertension management in these individuals.

Heart failure (HF), hypertension, and abnormal nocturnal blood pressure dipping are highly prevalent in hemodialysis patients. Atrial fibrillation (AF) and HF might be important mediators for the association of abnormal dipping patterns with worse prognosis. Thus, the aim of this study is to investigate the association of dipping with mortality in hemodialysis patients and to assess the influence of AF and HF. In total, 525 hemodialysis patients underwent 24-hour ambulatory blood pressure monitoring. All-cause and cardiovascular mortality served as end points. Patients were categorized according to their systolic dipping pattern (dipper, nondipper, and reverse dipper). Cox regression analysis was performed to determine the association between dipping pattern and study end points with dipping as reference. Subgroup analysis was performed for patients with and without AF or HF. In total, 185 patients with AF or HF and 340 patients without AF or HF were included. During a median follow-up of 37.8 months, 177 patients died; 81 from cardiovascular causes. Nondipping and reverse dipping were significantly associated with all-cause mortality in the whole cohort (nondipper: hazard ratio, 1.95 [1.22–3.14]; P =0.006; reverse dipper: hazard ratio, 2.31 [1.42–3.76]; P P =0.02; reverse dipper: hazard ratio, 4.48 [1.87–10.71]; P

Background and Aims Earlier studies that were based on routine clinic blood pressure (BP) recordings suggested that the prevalence of hypertension is lower in patients on peritoneal dialysis (PD) than in those receiving maintenance hemodialysis. These studies, however, did not incorporate the “gold-standard” method of ambulatory BP monitoring (ABPM). The aim of the present study was to quantify the prevalence and control of hypertension in a cohort of 81 peritoneal dialysis (PD) patients using clinic and ambulatory BP recordings. Method Triplicate BP recordings were obtained after a 5-minute seated rest at clinic with the validated monitor HEM-705 CP (Omron, HealthCare). 24-hour ABPM was subsequently performed with the Mobil-O-Graph device (IEM, Germany). Hypertension was defined as (i) average clinic BP ≥140/90 mmHg or antihypertensive drug use and (ii) 24-hour BP ≥130/80 mmHg or current use of antihypertensive drugs. Results The prevalence of hypertension was 92.6% with clinic BP recordings and 93.8 with ABPM. In all, 75 participants (92.6%) were receiving therapy with an average of 2.4 antihypertensive medications. The rates of adequate control of hypertension were 49.3% with the use of clinic BP recordings and 39.5% with ABPM, respectively. In all, 6.2% of participants were classified as normotensives, 33.3% had concordant control of hypertension with both techniques, 40.7% had concordant lack of control confirmed by both techniques, 5% had “white coat” hypertension and 14.8% had masked uncontrolled hypertension. Conclusion This study suggests that the burden of hypertension among patients on PD is very high and that the wider use of ABPM is important to confirm the BP control status of these patients.

Background: Short-term blood pressure (BP) variability (BPV) is associated with increased cardiovascular risk in hemodialysis. Patients with intradialytic hypertension have high risk of adverse outcomes. Whether BPV is increased in these patients is not clear. The purpose of this study was to compare short-term BPV in patients with and without intradialytic hypertension. Methods: Forty-one patients with and 82 patients without intradialytic hypertension (intradialytic SBP rise ≥10 mm Hg to > 150 mm Hg) matched in a 1: 2 ratio for age, sex, and hemodialysis vintage were included. All subjects underwent 48-h ambulatory BP monitoring during a regular hemodialysis and the subsequent interdialytic interval. Brachial and aortic BPV were calculated with validated formulas and compared between the 2 groups during the 48-h and the 44-h periods and during the 2 daytime and nighttime periods respectively. Results: During 48-h or 44-h periods and daytime or nighttime, brachial SBP/DBP and aortic SBP/DBP were significantly higher in cases than in controls. All brachial SBP/DBP BPV indexes [SD, weighted SD (wSD), coefficient-of-variation (CV) and average-real-variability (ARV)] were not significantly different between groups during the 48- or 44-h periods (48-h: SBP-ARV 11.59 ± 3.05 vs. 11.70 ± 2.68, p = 0.844, DBP-ARV: 8.60 ± 1.90 vs. 8.90 ± 1.63, p = 0.357). Analysis stratified by day or night between days 1 and 2 revealed, in general, similar results. No significant differences in dipping pattern were observed between groups. Analysis of aortic BPV had similar findings. Conclusions: BPV is similar between those with and without intradialytic hypertension. However, those with intradialytic hypertension have a sustained increase in systolic and diastolic BP during the entire interdialytic interval.

Rationale & Objective Current recommendations suggest the use of ambulatory blood pressure monitoring (ABPM) as the gold standard for hypertension diagnosis and management in hemodialysis patients. This study assesses the accuracy of peridialytic, intradialytic, and scheduled interdialytic recordings in detecting abnormally elevated 44-hour interdialytic blood pressure (BP). Study Design Diagnostic test study. Settings & Participants 242 Greek hemodialysis patients who successfully underwent ABPM. Tests Compared Ambulatory BP was used as the reference method to evaluate the accuracy of the following BP metrics: predialysis and postdialysis BP, intradialytic BP, intradialytic plus pre/postdialysis BP, and scheduled interdialytic BP (on an off-dialysis day at 8:00 am , 8:00 pm , and their average). Outcome 44-hour ambulatory systolic BP/diastolic BP (SBP/DBP) ≥ 130/80 mm Hg. Results The 44-hour SBP/DBP levels differed significantly from predialysis and postdialysis BP but showed no or minor differences compared with the other BP metrics. Bland-Altman plots showed an absence of systematic bias for all metrics but large between-method difference and wider 95% limits of agreement for predialysis and postdialysis BP compared with intradialytic, intradialytic plus pre/postdialysis, and averaged scheduled interdialytic BP. The sensitivity/specificity and κ-statistic for diagnosing 44-hour SBP ≥ 130 mm Hg were low for predialysis (86.5%/38.6%, κ-statistic = 0.27) and postdialysis BP (63.1%/73.3%, κ-statistic = 0.35), but better for intradialytic BP (77.3%/76.2%, κ-statistic = 0.53), intradialytic plus pre/postdialysis BP (76.6%/72.3%, κ-statistic = 0.49), and scheduled interdialytic BP (87.9%/77.2%, κ-statistic = 0.66). In receiver operating characteristic (ROC) analyses, the areas under the curve (AUC) of predialysis SBP (AUC = 0.723) and postdialysis SBP (AUC = 0.746) were significantly lower than that of intradialytic SBP (AUC = 0.850), intradialytic plus pre/postdialysis SBP (AUC = 0.850), and scheduled interdialytic SBP (AUC = 0.917) (z test, P Limitations Typical home BP data were not obtained, and no assessment was obtained of the reproducibility of the examined metrics over time. Conclusions Intradialytic, intradialytic plus pre/postdialysis, and scheduled interdialytic BP measurements were more accurate in detecting elevated 44-hour BP than predialysis and postdialysis BP. Averaged intradialytic BP recordings or scheduled readings at the off-dialysis day appear to be promising approaches to the diagnosis of elevated BP in hemodialysis.

Objectives Hemodialysis patients have premature arterial stiffness, and the relationship between pulse wave velocity (PWV) and blood pressure (BP) may be different than in other hypertensives. Previous studies in such patients showed that when BP decrease is accompanied by PWV decrease the survival is improved. This study examines the prognostic role of the mean BP (MBP)-PWV association for cardiovascular outcomes and all-cause mortality in hemodialysis. Methods A total of 242 hemodialysis patients underwent 48-h ambulatory BP monitoring with Mobil-O-Graph-NG and were followed for 33.17 ± 19.68 months. The within-individual MBP-PWV association (MBP, dependent and PWV independent variable) was evaluated using the β-coefficient value from simple linear regression analysis for each patient. The primary end-point was first occurrence of all-cause death, nonfatal myocardial infarction or nonfatal stroke. Secondary end-points were all-cause mortality, cardiovascular mortality and a combination of cardiovascular events. Results Higher quartiles of β-coefficients (indicating strong within-individual association of MBP with PWV) were related to greater cumulative freedom from the primary end-point (50.8, 60.0, 70.0 and 80.3% for quartiles 1-4, respectively; log-rank P = 0.001), better overall survival (60.7, 61.7, 73.3, 86.9%; log-rank P = 0.002) and better cardiovascular survival (78.7, 75.0, 81.7, 91.8% for quartiles 1-4; log-rank P = 0.044). The future risks of the primary end-point, all-cause and cardiovascular mortality and the combined outcome were progressively increasing with lower quartiles of β-coefficients, indicating patients with weak MBP-PWV association (hazard ratios for all-cause mortality 3.395; 95% confidence interval: 1.524-7.563, P = 0.003 for quartile 1 vs. quartile 4). Conclusion Weaker within-individual MBP-PWV association, based on ABPM recordings, is associated with higher risk of death and cardiovascular events in hemodialysis. These findings support that arterial stiffness insensitive to BP changes is the underlying factor for adverse outcomes in these individuals.

Introduction and purpose Hemodialysis patients have premature arterial stiffness, and the relationship between pulse wave velocity (PWV) and blood pressure (BP) may be different than in other hypertensives. Previous studies showed that when BP decrease is accompanied by PWV decrease the survival is improved. The aim of this study is to examine the prognostic significance of BP sensitivity of PWV for major cardiovascular outcomes and all-cause mortality in hemodialysis patients. Methods This is a prospective cohort study including 242 hemodialysis patients [age, 62.6±14.2 years; female, 91 (37.6%); hemodialysis vintage, 41.53±43.46]. All subjects underwent 48-hour-ABPM with Mobil-O-Graph-NG and followed-up for 33.17±19.68 months. The within-individual MBP-PWV association (MBP, dependent and PWV independent variable) was evaluated using the beta-coefficient value from simple linear regression analysis for each patient. The primary end-point was first occurrence of all-cause death, non-fatal myocardial infarction or non-fatal stroke. Secondary end-points were: (i) all-cause mortality; (ii) cardiovascular mortality; (iii) a combination of cardiovascular events. Results Patients who experienced the primary end-point during follow-up had significantly lower beta-coefficient levels (primary end-point: 19.877±3.975 vs 18.483±3.550, p=0.008). Higher quartiles of beta-coefficients (indicating dependency of PWV on MBP) were associated with higher cumulative freedom from the primary end-point (50.8%, 60.0%, 70.0% and 80.3% for quartiles 1 to 4 respectively; logrank-p=0.001), higher overall survival (60.7%, 61.7%, 73.3%, 86.9%; logrank-p=0.002) and higher cardiovascular survival (78.7%, 75.0%, 81.7%, 91.8% for quartiles 1 to 4; logrank-p=0.044). The future risk for the primary end-point, all-cause and cardiovascular mortality and the combined outcome was progressively increasing for lower quartiles of beta-coefficients (HR for all-cause mortality 3.395; 95% CI: 1.524–7.563, p=0.003 for quartile 1 vs quartile 4). Age (OR: 1.046, 95% CI: 1.016–1.077 per year increase, p=0.003) and 48h heart rate (OR: 0.949, 95% CI: 0.916–0.982 per bpm increase, p=0.003) were independently associated with weaker relationship between 48h-MBP and 48h-PWV. Conclusions Lower within-individual MBP-PWV association, based on AMBP recordings, is associated with higher risk of death and cardiovascular events in hemodialysis. These findings support that BP-independent arterial stiffness may be the underlying factor for adverse outcomes in these individuals.

Background Population-specific consensus documents recommend that the diagnosis of hypertension in haemodialysis patients be based on 48-h ambulatory blood pressure (ABP) monitoring. However, until now there is just one study in the USA on the prevalence of hypertension in haemodialysis patients by 44-h recordings. Since there is a knowledge gap on the problem in European countries, we reassessed the problem in the European Cardiovascular and Renal Medicine working group Registry of the European Renal Association-European Dialysis and Transplant Association. Methods A total of 396 haemodialysis patients underwent 48-h ABP monitoring during a regular haemodialysis session and the subsequent interdialytic interval. Hypertension was defined as (i) pre-haemodialysis blood pressure (BP) ≥140/90 mmHg or use of antihypertensive agents and (ii) ABP ≥130/80 mmHg or use of antihypertensive agents. Results The prevalence of hypertension by 48-h ABP monitoring was very high (84.3%) and close to that by pre-haemodialysis BP (89.4%) but the agreement of the two techniques was not of the same magnitude (κ statistics = 0.648; P Conclusions The prevalence of hypertension in haemodialysis patients assessed by 48-h ABP monitoring is very high. Pre-haemodialysis BP poorly reflects the 48 h-ABP burden. About a third of the haemodialysis population has white coat or masked hypertension. These findings add weight to consensus documents supporting the use of ABP monitoring for proper hypertension diagnosis and treatment in this population.

Background. Long-term pre-dialysis blood pressure variability (BPV) in haemodialysis patients is associated with increased cardiovascular risk. The association of the main haemodynamic culprit in dialysis, that is, short-term BPV, with outcomes has not been investigated. We examine the prognostic role of short-term BPV for mortality and cardiovascular events in this population. Methods. A total of 227 haemodialysis patients underwent 44-h ambulatory monitoring during a standard interval and were followed-up for 30.17 ± 17.70 months. We calculated SD, weighted SD (wSD), coefficient of variation (CV) and average real variability (ARV) of BP with validated formulas. The primary endpoint was first occurrence of all-cause death, non-fatal myocardial infarction or non-fatal stroke. Secondary endpoints were: (i) all-cause mortality, (ii) cardiovascular mortality and (iii) a combination of cardiovascular events. Results. Cumulative freedom from the primary endpoint was similar for quartiles of pre-dialysis and 44-h systolic BP (SBP), but was progressively longer for increasing quartiles of 44-h SBP-SD (P = 0.014), wSD (P = 0.007), CV (P = 0.031) and ARV (83.9, 71.9, 70.2 and 43.9% for quartiles 1-4; P < 0.001). Higher quartiles of 44-h SBP-ARV were associated with higher risk of all studied outcomes. Among diastolic BPV indices, 44-h diastolic BP (DBP)-CV and 44-h DBP-ARV were associated with increased risk for the composite cardiovascular outcome. In Cox regression analysis, SBP-BPV was related to the primary endpoint, independently of SBP levels and interdialytic weight gain [ARV: hazard ratio (HR) 1.115, 95% confidence interval (95% CI) 1.048-1.185]. This association become insignificant after adjustment for pulse wave velocity (PWV; HR 1.061, 95% CI 0.989-1.137), and further attenuated after additional adjustment for age, dialysis vintage, gender, comorbidities and prevalent cardiovascular disease (HR 1.031, 95% CI 0.946-1.122). Conclusions. Increased BPV during the interdialytic interval is associated with higher risk of death and cardiovascular events, whereas ambulatory BP levels are not. This association was not independent after adjustment for PWV, other risk factors and prevalent cardiovascular disease. Short-term BPV could be a mediator promoting the adverse cardiovascular profile of haemodialysis patients.

OBJECTIVES Intradialytic hypertension is estimated at 5-15% of hemodialysis patients and is associated with poor prognosis. Studies on therapeutic interventions for this entity are extremely few. We aimed to evaluate the effects of nebivolol and irbesartan on peridialytic, intradialytic, and ambulatory BP in patients with intradialytic hypertension. METHODS This is a pilot randomized-cross-over study in 38 hemodialysis patients (age: 60.4 ± 11.1 years, men: 65.8%) with intradialytic hypertension (intradialytic SBP rise ≥10 mmHg at ≥4 over six consecutive sessions]. After baseline evaluation, patients were randomly assigned to nebivolol 5 mg and subsequently irbesartan 150 mg, or vice versa. Nineteen patients received a single drug-dose 1 h before hemodialysis and 19 received the drug for a week before evaluation. A 2-week wash-out period took place before the initiation of the second drug. Patients had three respective 24-h ambulatory BP measurements starting before a midweek session. RESULTS In total, 20 (52.6%) patients received nebivolol first and 18 (47.4%) received irbesartan. Patients receiving a single dose of either drug had lower postdialysis BP (baseline: 160.2 ± 17.8/93.2 ± 13.6 mmHg; nebivolol: 148.0 ± 20.8/84.5 ± 13.1 mmHg, P = 0.013/P = 0.027; irbesartan 142.9 ± 29.9/87.2 ± 18.1 mmHg, P = 0.003/P = 0.104 for SBP and DBP, respectively). The 24-h BP presented a trend towards reduction, but was significant only for 24-h DBP in the nebivolol arm. Patients on weekly administration of either drug had lower postdialysis BP (baseline: 162.5 ± 16.8/95.4 ± 12.7 mmHg; nebivolol: 146.7 ± 16.3/91.8 ± 12.2 mmHg, P = 0.001/P = 0.235; irbesartan: 146.0 ± 23.9/85.8 ± 12.9 mmHg, P = 0.004/ P = 0.007, respectively), lower intradialytic BP and lower 24-h BP (baseline: 148.3 ± 12.6/90.2 ± 9.0 mmHg; nebivolol: 139.2 ± 10.6/85.0 ± 7.7 mmHg, P

Objective:Short-term BP variability (BPV) is associated with increased cardiovascular risk in hemodialysis. Patients with intradialytic hypertension have high risk of adverse outcomes and increased BPV may be an involved mechanism. This is the first study comparing short-term BPV in patients with an

Objective:The prevalence of non- and reverse-dipping is very high in hemodialysis patients. Evidence for the association of abnormal dipping patterns with worse prognosis has been reported previously. In hemodialysis, evidence is scarce and cardiac function might be an important mediator as has rece

Objective:We previously reported results of a European survey suggesting that standard recommendations for blood pressure (BP) measurement are poorly followed in dialysis centres. The objectives of the current sub-study were (i) to compare adherence to office BP measurement guidelines in dialysis ce

Objectives: Patients with end-stage renal-disease under hemodialysis have increased cardiovascular risk and experience severe blood pressure (BP) fluctuations during the dialysis session and the subsequent interdialytic period. BP variability (BPV) may be an additional risk factor for cardiovascular events and preliminary data suggest increased BPV with advancing stages of chronic kidney disease. This is the first study to examine BPV during the whole intradialytic and interdialytic period in hemodialysis patients with ambulatory BP monitoring. Methods: A total of 160 patients receiving maintenance hemodialysis had 48-h ambulatory BP monitoring with the Mobil-O-Graph device during a regular dialysis session and the subsequent interdialytic interval. Brachial and aortic BPV were calculated with validated formulas and were compared between Days 1 and 2 of the interdialytic period (44-h), Days 1 and 2 of the total 48-h interval (including the dialysis session), and between the two respective daytime periods and night-time periods. Results: All brachial SBPV indices [SD: 14.75±4.38 vs. 15.91±4.41, P=0.001; weighted SD: 13.80±4.00 vs. 14.89±3.90, P

Arterial stiffness and augmentation of aortic blood pressure (BP) measured in office are known cardiovascular risk factors in hemodialysis patients. This study examines the prognostic significance of ambulatory brachial BP, central BP, pulse wave velocity (PWV), and heart rate–adjusted augmentation index [AIx(75)] in this population. A total of 170 hemodialysis patients underwent 48-hour ambulatory monitoring with Mobil-O-Graph-NG during a standard interdialytic interval and followed-up for 28.1±11.2 months. The primary end point was a combination of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. Secondary end points included: (1) all-cause mortality; (2) cardiovascular mortality; and (3) a combination of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, resuscitation after cardiac arrest, coronary revascularization, or hospitalization for heart failure. During follow-up, 37(21.8%) patients died and 46(27.1%) had cardiovascular events. Cumulative freedom from primary end point was similar for quartiles of predialysis-systolic BP (SBP), 48-hour peripheral-SBP, and central-SBP, but was progressively longer for increasing quartiles for 48-hour peripheral-diastolic BP and central-diastolic BP and shorter for increasing quartiles of 48-hour central pulse pressure (83.7%, 71.4%, 69.0%, 62.8% [log-rank P =0.024]), PWV (93.0%, 81.0%, 57.1%, 55.8% [log-rank P P =0.014]). The hazard ratios for all-cause mortality, cardiovascular mortality, and the combined outcome were similar for quartiles of predialysis-SBP, 48-hour peripheral-SBP, and central-SBP, but were increasing with higher ambulatory PWV and AIx(75). In multivariate analysis, 48-hour PWV was the only vascular parameter independently associated with the primary end point (hazard ratios, 1.579; 95% confidence intervals, 1.187–2.102). Ambulatory PWV, AIx(75), and central pulse pressure are associated with increased risk of cardiovascular events and mortality, whereas office and ambulatory SBP are not. These findings further support that arterial stiffness is the prominent cardiovascular risk factor in hemodialysis.

Background/Aims: The hypothesis that dialytic modality affects arterial stiffness was never investigated. This study includes comparative evaluation of hemodiafiltration versus hemodialysis on arterial function during first and second weekly dialysis sessions. Methods: 24 patients receiving hemodiafiltration and another 24 age- and sex-matched controls receiving hemodialysis were included. Patients were evaluated before and after first and second weekly dialysis sessions. Applanation tonometry of peripheral arteries was applied to determine aortic and brachial pulse wave velocity and heart rate-adjusted augmentation index (AIx(75)). Results: Hemodiafiltration and hemodialysis reduced AIx(75), but not aortic and brachial pulse wave velocity. Intradialytic reductions in AIx(75) did not differ between hemodiafiltration and hemodialysis in first and mid-week dialysis. In multivariate linear regression, predictors of intradialytic reduction in AIx(75) were changes in body weight and central aortic systolic blood pressure, but not dialytic modality. Conclusion: This study showed that hemodiafiltration has similar effects with hemodialysis on wave reflections and stiffness.

Objective:Arterial stiffness and aortic blood pressure (BP) augmentation are significantly increased in hemodialysis patients. Recent studies suggest that the prognostic significance of ambulatory recordings of arterial stiffness is high in hemodialysis. This study examines for the first time the ef

Objective:Hemodialysis patients have premature arterial stiffness, and the relationship between pulse wave velocity (PWV) and blood pressure (BP) may be different than in other hypertensives. Previous studies showed that when BP decrease is accompanied by PWV decrease the survival is improved. The a

Objective:Left (LV) and right (RV) ventricular diastolic dysfunction is highly prevalent in hemodialysis patients (50%–75%). Hypertension and increased preload due to hypervolemia are major factors for the pathogenesis of ventricular dilatation and dysfunction in these patients. This study examined

BACKGROUND Increased arterial stiffness is a common finding and independent predictor of mortality in end-stage renal disease (ESRD) patients. A long interdialytic interval was associated with increased risk of cardiovascular death in patients receiving conventional haemodialysis (HD). This is the first study to examine the effects of a long (3-day) versus short (2-day) interdialytic period on arterial elasticity in HD patients. METHODS Seventy ESRD patients receiving standard HD three times per week were studied at the start and end of a 3-day and a 2-day interdialytic interval. At each time point, applanation tonometry of peripheral arteries was performed to assess arterial stiffness and wave reflection parameters. Aortic and brachial pulse wave velocities (PWV) were recorded as measures of arterial stiffness and augmentation index (AIx) as a measure of wave reflections. RESULTS AIx, heart-rate-adjusted AIx and augmentation pressure were significantly increased during both interdialytic intervals, whereas aortic and brachial PWVs remained unchanged. The interdialytic increases in all the three AIx parameters were significantly higher during the 3-day interval in comparison to the 2-day interval (P < 0.001 for all comparisons). In contrast, no significant differences in interdialytic changes of aortic (P = 0.355) and brachial (P = 0.319) PWVs were noted between the two intervals. Mixed linear model analysis revealed that central aortic systolic blood pressure (SBP) and body weight, but not aortic or brachial PWV, were independent determinants of the change in heart-rate-adjusted AIx throughout the study. CONCLUSIONS AIx is increased between HD sessions, whereas arterial elasticity is not. This interdialytic increase in central wave augmentation is more pronounced during the 3-day interval, suggesting a mechanism possibly involved in the elevated cardiovascular risk of HD patients at this time point.