Association of intradialytic blood pressure changes with hospitalization and mortality rates in prevalent ESRD patients

Impact of intradialytic blood pressure changes on cardiovascular outcomes is independent of the volume status of maintenance hemodialysis patients

Intradialytic systolic blood pressure (SBP) changes are related to the volume status; however, whether SBP change impacts on adverse outcomes depends on the volume status remains uncertain. We retrospectively investigated the relationship among intradialytic changes in SBP, cardiovascular outcomes, and volume status in maintenance hemodialysis patients. We determined SBP changes (ΔSBP) as postdialysis SBP minus predialysis SBP and volume status as the ratio of extracellular water to total body water (ECW/TBW) using bioelectrical impedance analysis. There were 82 (60.3%) with ΔSBP -20 to 10 mm Hg, 21 (15.4%) with ΔSBP ≤ -20 mm Hg, and 33 (24.3%) with ΔSBP ≥ 10 mm Hg, and they were followed up for a median of 34 months. Cardiovascular events more frequently occurred in the patients with ΔSBP ≤ -20 mm Hg and ≥ 10 mm Hg (hazard ratio: 2.3 and 3.0; P = .062 and .006); these associations persisted even after adjusting for postdialysis ECW/TBW (P = .056 and .028). Moreover, ΔSBP ≥ 10 mm Hg was associated with increased cardiovascular mortalities independent of postdialysis ECW/TBW (P = .043). There was an independent association of volume status between considerable SBP decrease or increase during hemodialysis and adverse cardiovascular outcomes. Besides appropriate volume control, other factors related to BP changes during hemodialysis must be investigated.

The Association between Intradialytic Hypertension and Metabolic Disorders in End Stage Renal Disease

Background

Intradialytic hypertension was associated with a high mortality risk. We examined the relationship between intradialytic hypertension and metabolic disorders in hemodialysis treatment patients.

Methods

We studied 76 patients in online hemodiafiltration. Dialysis adequacy was defined by Kt/V for urea. Normalized protein catabolic rate (nPCR), as a marker of protein intake, was calculated. Sodium removal was determined as percent sodium removal. Metabolic acidosis was determined by serum bicarbonate less than 22 mmol/L. Interdialytic urine volume more than 100 ml was recorded. Intradialytic hypertension was defined by an increase in systolic blood pressure equal to 10 mmHg from pre- to posthemodialysis. Arterial stiffness was assessed as carotid-femoral pulse wave velocity (c-fPWV) and carotid augmentation index (AIx). Chi-square tests and logistic regression analysis were applied for intradialytic hypertension prediction.

Results

Patients with intradialytic hypertension were older and had significantly lower hemoglobin, nPCR, urine output, and serum bicarbonate and significantly higher c-fPWV, though similar Kt/V for urea, than patients without intradialytic hypertension. They also had increased sodium removal and pulse pressure related to less urine output. Serum bicarbonate was inversely associated with c-fPWV (r = -0.377, p = 0.001). Chi-square test showed significant association between intradialytic hypertension and serum bicarbonate < 22 mmol/L (x² = 5.6, p = 0.01), which was supported by an adjusted model.

Conclusion

The intradialytic hypertension was significantly associated with metabolic disorders including malnutrition/inflammation and uncontrolled metabolic acidosis in hemodialysis treatment patients. Severe metabolic acidosis may reflect sodium imbalance and hemodynamic instability of these patients resulting in volume overload and increased vascular resistance.

Association of Intradialytic Hypertension with Left Ventricular Mass in Hypertensive Hemodialysis Patients Enrolled in the Blood Pressure in Dialysis (BID) Study

BACKGROUND/AIMS

Intradialytic hypertension (IDH), or paradoxical rise in blood pressure (BP) during hemodialysis (HD) is associated with increased morbidity and mortality. The association between IDH and increased left ventricular mass (LVM), a well-known risk factor for adverse cardiovascular outcomes in HD patients, has not been studied. The aim of our study is to evaluate the cross-sectional association of intradialytic change in BP with cardiac structure and function measured by cardiac MRI in hypertensive HD patients enrolled in the multi-center Blood Pressure in Dialysis (BID) clinical trial.

METHODS

Participants in the BID study were categorized into 3 groups based on average change (Δ) in systolic blood pressure (SBP) (post-HD SBP minus pre-HD SBP) during HD over a 1 month period: group 1 - patients with an increase in SBP ≥ 10mm Hg during HD (IDH); group 2 -patients with SBP decrease of greater ≥10mm Hg during HD; group 3 - patients with SBP increase or decrease by < 10mm Hg during HD. LVM index (LVMI) was measured using cardiac MRI, which were centrally read. Baseline characteristics were compared in the 3 groups and multivariable regression models were fitted for the adjusted association of IDH with LVMI.

RESULTS

Among the 80 participants, 7 (8.8%) had IDH and had average Δ SBP 17.0 ± 10.1 mmHg during HD. Patients with IDH were less likely to be diabetic, had lower pre-dialysis SBP and lower percent interdialytic weight gain as compared to the other 2 groups (p=0.02, p< 0.001 and p=0.02 respectively). In multivariable regression analyses, IDH was significantly associated with LVMI (adjusted mean difference relative to SBP decreased group [95% confidence interval (CI)] = 12.5 [3.6, 21.5], p=0.01) after adjusting for age, sex, diabetes, IDWG%, pre-HD SBP and beta blocker use. Every 1 mm rise in ΔSBP during HD was associated with 0.2 g/m2 increase in LVMI in adjusted models (p=0.04).

CONCLUSION

IDH is independently associated with higher LVMI in hypertensive HD patients and may contribute to increased cardiovascular events.

Intradialytic blood pressure pattern recognition based on density peak clustering

End-stage renal disease (ESRD) is the final stage of chronic kidney disease (CKD) and requires hemodialysis (HD) for survival. Intradialytic blood pressure (IBP) measurements are necessary to ensure patient safety during HD treatments and have critical clinical and prognostic significance. Studies on IBP measurements, especially IBP patterns, are limited. All related studies have been based on a priori knowledge and artificially classified IBP patterns. Therefore, the results were influenced by subjective concepts. In this study, we proposed a new approach to identify IBP patterns to classify ESRD patients. We used the dynamic time warping (DTW) algorithm to measure the similarity between two series of IBP data. Five blood pressure (BP) patterns were identified by applying the density peak clustering algorithm (DPCA) to the IBP data. To illustrate the association between BP patterns and prognosis, we constructed three random survival forest (RSF) models with different covariates. Model accuracy was improved 3.7-6.3% by the inclusion of BP patterns. The results suggest that BP patterns have critical clinical and prognostic significance regarding the risk of cerebrovascular events. We can also apply this clustering approach to other time series data from electronic health records (EHRs). This work is generalizable to analyses of dense EHR data.

The effect of an L/N-type calcium channel blocker on intradialytic blood pressure in intradialytic hypertensive patients

BACKGROUND

Intradialytic hypertension (HTN), which is one of the poor prognostic markers in patients undergoing hemodialysis, may be associated with sympathetic overactivity. The L/N-type calcium channel blocker, cilnidipine, has been reported to suppress sympathetic nerves activity in vivo. Therefore, we hypothesized that cilnidipine could attenuate intradialytic systolic blood pressure (SBP) elevation.

METHODS

Fifty-one patients on chronic hemodialysis who had intradialytic-HTN (SBP elevation ≥10 mmHg during hemodialysis) and no fluid overload were prospectively randomized into two groups: control and cilnidipine groups. Cilnidipine group patients took cilnidipine (10 mg/day) for 12 weeks. The primary endpoint was the change in the intradialytic SBP elevation before and after the 12-week intervention.

RESULTS

Before the intervention, no differences were observed in age, sex or pre-dialytic SBP (148.5 ± 12.9 vs. 148.3 ± 19.3 mmHg) between the two groups. Intradialytic SBP elevation was unchanged in the control group. Cilnidipine significantly lowered the post-dialytic SBP with an attenuation of the intradialytic SBP elevation from 12.0 ± 15.4 mmHg to 4.8 ± 10.1 mmHg. However, the observed difference in the intradialytic SBP elevation by cilnidipine did not reach statistical significance (group×time interaction effect p = 0.25). Cathecolamine levels were unaffected by the intervention in both groups.

CONCLUSION

Cilnidipine lowers both the pre- and post-dialytic SBP and might attenuate intradialytic SBP elevation. Therefore, cilnidipine may be effective in lowering SBP during HD in patients with intradialytic-HTN.

Intradialytic Hypertension Frequency and Short-Term Clinical Outcomes Among Individuals Receiving Maintenance Hemodialysis

BACKGROUND

Intradialytic hypertension occurs in 5-20% of hemodialysis treatments. Observational data support an association between intradialytic hypertension and long-term mortality. However, the short-term consequences of recurrent intradialytic hypertension are unknown.

METHODS

Data were taken from a cohort of prevalent hemodialysis patients receiving treatment at a large United States dialysis organization on 1 January 2010. A retrospective cohort design with a 180-day baseline, 30-day exposure assessment, and 30-day follow-up period was used to estimate the associations between intradialytic hypertension frequency and 30-day outcomes. Intradialytic hypertension frequency was defined as the proportion of exposure period hemodialysis treatments with a predialysis to postdialysis systolic blood pressure rise >0 mm Hg. Multivariable Cox proportional hazards regression, adjusted for baseline clinical, laboratory, and dialysis treatment covariates, was used to estimate hazard ratios and 95% confidence intervals.

RESULTS

Of the 37,094 study patients, 5,242 (14.1%), 17,965 (48.4%), 10,821 (29.2%), 3,066 (8.3%) had intradialytic hypertension in 0%, 1-32%, 33-66%, and ≥67% of exposure period treatments, respectively. More frequent intradialytic hypertension was associated with incremental increases in 30-day mortality and hospitalizations. Patients with intradialytic hypertension in ≥67% (vs. 0%) of exposure period treatments had the highest risk of all-cause death, hazard ratio [95% confidence interval]: 2.57 [1.68, 3.94]; cardiovascular (CV) death, 3.68 [1.89, 7.15]; all-cause hospitalizations, 1.42 [1.26, 1.62]; CV hospitalizations, 1.71 [1.36, 2.15]; and volume-related hospitalizations, 2.25 [1.25, 4.04].

CONCLUSIONS

Among prevalent hemodialysis patients, more frequent intradialytic hypertension was incrementally associated with increased 30-day morbidity and mortality. Intradialytic hypertension may be an important short-term risk marker in the hemodialysis population.

The Prevalence of Persistent Intradialytic Hypertension in a Hemodialysis Population with Extended Follow-Up

Background

Intradialytic hypertension, a phenomenon where blood pressure increases during hemodialysis, is associated with increased mortality in hemodialysis patients. The proportion of patients in which intradialytic hypertension persists over time is unknown.

Methods

In a retrospective cohort study, we studied all patients from our outpatient hemodialysis units that received ≥1 month of treatments during the period from January to August 2010. We reviewed all pre- and post-hemodialysis blood pressure and weight measurements from 22,955 treatments during this study period. We defined intradialytic hypertension as an increase in systolic blood pressure ≥10 mmHg from pre- to post-hemodialysis. Individual patients were defined as having persistent intradialytic hypertension if the change in blood pressure from pre- to post-hemodialysis, when averaged throughout the study period, was ≥+10 mmHg. We calculated weight changes between and during hemodialysis and defined ultrafiltration rate per treatment as ultrafiltration volume divided by minutes on hemodialysis. We compared patients with and without persistent intradialytic hypertension using chi-square analysis and mixed linear models.

Results

The prevalence of intradialytic hypertension was 21.3 per 100 treatments. The median percentage of intradialytic hypertension treatments per patient was 17.8% (9–31.3%, interquartile range). The prevalence of persistent intradialytic hypertension was 8 per 100 patients. Patients with persistent intradialytic hypertension had lower ultrafiltration rate compared to other patients (10.4 vs. 12.2 ml/min, p = 0.02).

Conclusions

Intradialytic hypertension is a persistent phenomenon in a subset of hemodialysis patients. Ultrafiltration rate was the only volume-related variable that differed between patients with and without persistent intradialytic hypertension.

The Association between Intradialytic Hypertension and Metabolic Disorders in End Stage Renal Disease

BACKGROUND

Intradialytic hypertension was associated with a high mortality risk. We examined the relationship between intradialytic hypertension and metabolic disorders in hemodialysis treatment patients.

METHODS

We studied 76 patients in online hemodiafiltration. Dialysis adequacy was defined by Kt/V for urea. Normalized protein catabolic rate (nPCR), as a marker of protein intake, was calculated. Sodium removal was determined as percent sodium removal. Metabolic acidosis was determined by serum bicarbonate less than 22 mmol/L. Interdialytic urine volume more than 100 ml was recorded. Intradialytic hypertension was defined by an increase in systolic blood pressure equal to 10 mmHg from pre- to posthemodialysis. Arterial stiffness was assessed as carotid-femoral pulse wave velocity (c-fPWV) and carotid augmentation index (AIx). Chi-square tests and logistic regression analysis were applied for intradialytic hypertension prediction.

RESULTS

Patients with intradialytic hypertension were older and had significantly lower hemoglobin, nPCR, urine output, and serum bicarbonate and significantly higher c-fPWV, though similar Kt/V for urea, than patients without intradialytic hypertension. They also had increased sodium removal and pulse pressure related to less urine output. Serum bicarbonate was inversely associated with c-fPWV (r = -0.377, p = 0.001). Chi-square test showed significant association between intradialytic hypertension and serum bicarbonate < 22 mmol/L (x² = 5.6, p = 0.01), which was supported by an adjusted model.

CONCLUSION

The intradialytic hypertension was significantly associated with metabolic disorders including malnutrition/inflammation and uncontrolled metabolic acidosis in hemodialysis treatment patients. Severe metabolic acidosis may reflect sodium imbalance and hemodynamic instability of these patients resulting in volume overload and increased vascular resistance.

Blood pressure variation and its correlates among patients undergoing hemodialysis for renal failure in Benin City, Nigeria

Background:

Blood pressure (BP) variation is commonly encountered during hemodialysis (HD) procedure. Both intradialysis hypotension and hypertension have implications for outcome of treatment and overall morbidity and mortality of the patients.

Methodology:

A retrospective study was carried out in the dialysis unit of a tertiary health institution in Benin City among patients who had HD for acute kidney injury (AKI) or chronic kidney disease (CKD) over a 3-year period. Data retrieved included age, gender, type of kidney disease, cause of kidney disease, systolic BP at onset of dialysis and at end of dialysis, and diastolic BP (DBP) at onset of and at end of dialysis.

Results:

Complete data were available for 217 patients. One hundred and seven patients (49.3%) had no significant change in BP; 30.9% had intradialytic hypertension (IDHT) while 19.8% had intradialytic hypotension (IDH). IDH was more prevalent among patients with diabetic kidney disease while IDHT was more common among patients with hypertensive nephropathy (P = 0.002). Female patients had higher mean BP parameters compared to male patients pre- and post-dialysis, but only changes in DBP were statistically significant (P = 0.029). Patients with CKD had higher mean BP parameters pre- and post-dialysis compared to patients with acute AKI and the differences were statistically significant.

Conclusion:

Females had higher mean BP parameters than males. Patients with CKD had higher mean BP parameters compared with AKI patients. IDHT is a significant problem among patients on HD in our center. Measures to curtail this trend should be instituted with the goal of reducing morbidity and mortality.

Definitions of intradialytic hypotension

Intradialytic hypotension (IDH) is a common and often distressful complication of hemodialysis. However, despite its clinical significance, there is no consensus, evidence-based medical definition for the condition. Over the years, numerous definitions have been implemented in both the clinical and research settings. Definition inconsistencies have hindered data synthesis and the development of evidence-based guidelines for the prevention and treatment of IDH, as well as prevented accurate estimation of the population burden of IDH and patient risk assessment. Most existing IDH definitions are comprised of one or more of the following components: (1) intradialytic BP criteria (requisite BP declines or minimum BP thresholds), (2) the provision of interventions aimed at restoring effective arterial volume, and/or (3) patient-reported symptoms. Remarkably, there are insufficient data to inform IDH definition construction, and it remains unknown if a single, universal definition can adequately capture the condition across patient subgroups, and in clinical and research settings.

Central venous pressure and ultrasonographic measurement correlation and their associations with intradialytic adverse events in hospitalized patients: A prospective observational study

PURPOSE

To investigate correlation of central venous pressure (CVP) with ultrasonographic measurement of central veins, along with association between these variables and occurrence of intradialytic adverse events in hospitalized patients.

MATERIALS AND METHODS

Patients requiring hemodialysis via dialysis catheter were prospectively enrolled. CVP measurements through catheter, internal jugular vein aspect ratio, subclavian vein collapsibility, inferior vena cava (IVC) maximal diameter, and IVC collapsibility were recorded before and after hemodialysis. Predictive accuracy of ultrasonographic measurements in discriminating high versus low CVP and their association with intradialytic adverse events were evaluated. Area under receiver operating characteristic curves (AUCs) were calculated.

RESULTS

Fifty-nine patients were enrolled. Median (interquartile range) pre- and post-dialysis CVPs were 8 (4-13)mmHg and 6 (3-10)mmHg, respectively (P<0.01). In pre-dialysis, IVC collapsibility had the highest AUC (0.79, P<0.01) to predict CVP >8mmHg. In post-dialysis, IVC maximal diameter had the highest AUC (0.86, P<0.01) to predict CVP ≤4mmHg. Fifteen patients (25%) had adverse events. Neither pre-dialytic CVP nor ultrasonographic variables were associated with occurrence of adverse events.

CONCLUSIONS

Highest accuracy in predicting low and high CVP was observed with ultrasonographic assessment of IVC diameter and collapsibility. Adverse events were not predicted by pre-dialytic CVP or ultrasonographic measurements.

The relationship between survival rate and intradialytic blood pressure changes in maintenance hemodialysis patients

Objective: The objective of this study is to investigate the relationship between blood pressure changes and all-cause mortality, and between blood pressure changes and cardiovascular mortality, for maintenance hemodialysis (MHD) patients during dialysis.

Methods: Data regarding general condition, biochemical indices, and survival prognosis of MHD patients who were treated at the Shanghai Jiao Tong University School of Medicine-affiliated Renji Hospital from July 2007 to December 2012 were collected, in order to evaluate the relationship between patients’ blood pressure changes during hemodialysis and mortality.

Results: Among 364 patients, with an average age of 63.07 ± 13.93 years, an average dialysis vintage of 76.00 (range, 42.25–134.00) months, and a follow-up time of 54.86 ± 19.84 months, there were 85 cases (23.4%) of all-cause death and 46 cases (14.2%) of cardiovascular death. All-cause mortality and cardiovascular mortality were lowest (OR, 0.324 and 0.335; 95% CI, 0.152–0.692 and 0.123–0.911; p value, .004 and .032, respectively) in patients whose systolic blood pressure difference (ΔSBP) before and after dialysis was between 7.09 and 14.25 mmHg. Kaplan–Meier analysis indicated that both all-cause mortality and cardiovascular mortality were markedly increased for patients with ΔSBPless than −0.25 mmHg (p value, .001 and .044, respectively). Cox regression analysis showed that ΔSBP< −0.25 mmHg, hemoglobin concentration, Kt/v and albumin were independent risk factors for all-cause mortality in MHD patients.

Conclusions: MHD patients whose blood pressure increased significantly after hemodialysis had a higher risk of dying; ΔSBP, hemoglobin concentration, Kt/v and albumin were independent risk factors for all-cause mortality in MHD patients.

Intra-dialytic hypertension is associated with high mortality in hemodialysis patients

BACKGROUND

Intra-dialytic hypertension (IDH) is emerging as an important issue in hemodialysis patients. Its risk factors and clinical outcomes are unclear.

METHODS

A total of 73 prevalent hemodialysis patients were enrolled. They included 14 (19.2%) patients with baseline IDH and 59 patients without IDH. Their clinical parameters, laboratory parameters, and mortality were investigated over 78 months.

RESULTS

The risks factor of IDH included low serum potassium levels, low ultrafiltration, and low arm muscle area. Lower median survival was evident in the IDH group compared to the non-IDH group, but was not significantly different. After adjusting for relevant confounders for age, the IDH group displayed 2.846 times higher mortality rate than the non-IDH Group (adjusted hazard ratio: 2.846; 95% confidence interval: 1.081-7.490; P = 0.034).

CONCLUSION

IDH is associated with high mortality in hemodialysis patients. Clinicians should be aware of the risk factors. Future research studies are needed to explore the mechanisms involved in the association between IDH and mortality.

Special situations: Intradialytic hypertension/chronic hypertension and intradialytic hypotension

Hypertension is a comorbidity that is present in the majority of end-stage renal disease patients on maintenance hemodialysis. This population is particularly unique because of the dynamic nature of blood pressure (BP) during dialysis. Modest BP decreases are expected in most hemodialysis patients, but intradialytic hypotension and intradialytic hypertension are two special situations that deviate from this as either an exaggerated or paradoxical response to the dialysis procedure. Both of these phenomena are particularly important because they are associated with increased mortality risk compared to patients with modest decreases in BP during dialysis. While the detailed pathophysiology is complex, intradialytic hypotension occurs more often in patients prescribed fast ultrafiltration rates, and reducing this rate is recommended in patients that regularly exhibit this pattern. Patients with intradialytic hypertension have a poorly explained increase in vascular resistance during dialysis, but the consistent associations with extracellular volume overload point toward more aggressive fluid management as the initial management choices for these patients. This up to date review provides the most recent evidence supporting these recommendations as well as the most up to date epidemiologic and mechanistic research studies that have added to this area of dialysis management.

Analysis of proportional mean residual life model with latent variables

End-stage renal disease (ESRD) is one of the most serious diabetes complications. Numerous studies have been devoted to revealing the risk factors of the onset time of ESRD. In this article, we propose a proportional mean residual life (MRL) model with latent variables to assess the effects of observed and latent risk factors on the MRL function of ESRD in a cohort of Chinese type 2 diabetic patients. The proposed model generalizes the conventional proportional MRL model to accommodate the latent risk factor that cannot be measured by a single observed variable. We employ a factor analysis model to characterize the latent risk factors via multiple observed variables. We develop a borrow-strength estimation procedure, which incorporates the expectation-maximization algorithm and an extended estimating equation approach. The asymptotic properties of the proposed estimators are established. Simulation shows that the performance of the proposed methodology is satisfactory. The application to the study of type 2 diabetes reveals insights into the prevention of ESRD. Copyright © 2016 John Wiley & Sons, Ltd.

The influence of time point of blood pressure measurement on the outcome in hemodialysis patients

The blood pressure (BP) behaviors of hemodialysis (HD) population presented a unique pattern much different from that of the general population. This pattern is composed of chronic BP burden over interdialytic period and acute BP fluctuation during dialysis sessions. Peridialysis, interdialysis, and intradialysis are three routinely used time points to capture this complex BP behavior. However, BP at each time point was measured in various forms and conveyed different prognostic information. The measurement and interpretation of the tide-like BP behavior in HD population posed great challenge. In this review, we focused on the prognostic information of the BP behavior at each time point in HD patients and further discussed the optimal measurement of this unique BP behavior to best capture the BP-outcome association.

Hypertension in the Hemodialysis Patient

Hypertension is common yet difficult to manage in the hemodialysis patients population. This chapter discusses various aspects of this problem including its prevalence, distinctive pathophysiology, methods of diagnosis and pharmacological and non pharmacological treatment approaches. The topic is relevant to any health care provider taking care of hemodialysis patients.

Extracellular Volume Overload and Increased Vasoconstriction in Patients With Recurrent Intradialytic Hypertension

Background/Aims

Intradialytic hypertension (IH) occurs frequently in some hemodialysis patients and increases mortality risk. We simultaneously compared pre-dialysis, post-dialysis and changes in extracellular volume and hemodynamics in recurrent IH patients and controls.

Methods

We performed a case-control study among prevalent hemodialysis patients with recurrent IH and hypertensive hemodialysis controls. We used bioimpedance spectroscopy and impedance cardiography to compare pre-dialysis, post-dialysis, and intradialytic change in total body water (TBW) and extracellular water (ECW), as well as cardiac index (CI) and total peripheral resistance index (TPRI).

Results

The ECW/TBW was 0.453 (0.05) pre-dialysis and 0.427 (0.04) post-dialysis in controls vs. 0.478 (0.03) and 0.461 (0.03) in IH patients (p=0.01 post-dialysis). The ECW/TBW change was −0.027 (0.03) in controls and −0.013 (0.02) in IH patients (p=0.1). In controls, pre- and post-dialysis TPRI were 3254 (994) and 2469 (529) dynes/sec/cm²/m² vs. 2983 (747) and 3408 (980) dynes/sec/cm²/m² in IH patients (p=0.002 post-dialysis). There were between-group differences in TPRI change (0=0.0001), but not CI (p=0.09).

Conclusions

Recurrent intradialytic hypertension is associated with higher post-dialysis extracellular volume and TPRI. Intradialytic TPRI surges account for the vasoconstrictive state post-dialysis, but intradialytic fluid shifts may contribute to post-hemodialysis volume expansion.

Blood pressure variability and cardiovascular disease: systematic review and meta-analysis

OBJECTIVE

 To systematically review studies quantifying the associations of long term (clinic), mid-term (home), and short term (ambulatory) variability in blood pressure, independent of mean blood pressure, with cardiovascular disease events and mortality.

DATA SOURCES

 Medline, Embase, Cinahl, and Web of Science, searched to 15 February 2016 for full text articles in English.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

 Prospective cohort studies or clinical trials in adults, except those in patients receiving haemodialysis, where the condition may directly impact blood pressure variability. Standardised hazard ratios were extracted and, if there was little risk of confounding, combined using random effects meta-analysis in main analyses. Outcomes included all cause and cardiovascular disease mortality and cardiovascular disease events. Measures of variability included standard deviation, coefficient of variation, variation independent of mean, and average real variability, but not night dipping or day-night variation.

RESULTS

 41 papers representing 19 observational cohort studies and 17 clinical trial cohorts, comprising 46 separate analyses were identified. Long term variability in blood pressure was studied in 24 papers, mid-term in four, and short-term in 15 (two studied both long term and short term variability). Results from 23 analyses were excluded from main analyses owing to high risks of confounding. Increased long term variability in systolic blood pressure was associated with risk of all cause mortality (hazard ratio 1.15, 95% confidence interval 1.09 to 1.22), cardiovascular disease mortality (1.18, 1.09 to 1.28), cardiovascular disease events (1.18, 1.07 to 1.30), coronary heart disease (1.10, 1.04 to 1.16), and stroke (1.15, 1.04 to 1.27). Increased mid-term and short term variability in daytime systolic blood pressure were also associated with all cause mortality (1.15, 1.06 to 1.26 and 1.10, 1.04 to 1.16, respectively).

CONCLUSIONS

 Long term variability in blood pressure is associated with cardiovascular and mortality outcomes, over and above the effect of mean blood pressure. Associations are similar in magnitude to those of cholesterol measures with cardiovascular disease. Limited data for mid-term and short term variability showed similar associations. Future work should focus on the clinical implications of assessment of variability in blood pressure and avoid the common confounding pitfalls observed to date.

SYSTEMATIC REVIEW REGISTRATION

 PROSPERO CRD42014015695.

Intradialytic hypertension during chronic haemodialysis and subclinical fluid overload assessed by bioimpedance spectroscopy

BACKGROUND

Intradialytic hypertension (IDH) increases morbidity and mortality. The prevalence in South Africa is unknown. The pathogenesis is unclear, but it has been suggested that IDH may be due to subclinical fluid overload. The objective of this study was to determine the prevalence of IDH and to evaluate its association with fluid overload using bioimpedance spectroscopy (BIS).

METHODS

A cross-sectional study involving 190 chronic haemodialysis patients in the Western Cape province of South Africa was conducted between January 2013 and May 2014. IDH was defined as a >10 mmHg increase in systolic blood pressure in at least four of six prior consecutive haemodialysis sessions.

RESULTS

The prevalence of IDH was 28.4% (n = 54). There was a trend towards pre-dialysis overhydration in the IDH group when compared with controls {2.6 L [95% confidence interval (CI) 1.7-3.4] versus 1.8 L [95% CI 1.4-2.1], respectively; P = 0.06} as measured by BIS, but no difference in mean ultrafiltration (UF) volume (2.4 versus 2.6 L; P = 0.30). A trend towards greater use of antihypertensive drugs was noted in the IDH group [2.5 drugs (95% CI 2.15-2.87) versus 2.1 (95% CI 1.82-2.30); P = 0.05]. More participants in the IDH group received calcium channel blockers (54 versus 36; P = 0.03).

CONCLUSIONS

The prevalence of IDH in our treatment centres is much higher than previously reported. Subclinical fluid overload may be a major contributing factor to the mechanism of this condition. The use of BIS identifies patients who may benefit from additional UF.

Postdialysis Hypertension: Associated Factors, Patient Profiles, and Cardiovascular Mortality

BACKGROUND AND OBJECTIVES

A postdialytic increase in blood pressure (BP) is a recognized but often an overlooked complication. The epidemiology and predisposing factors are still not well defined. We studied a large sample of Italian dialysis patients to assess the prevalence of postdialysis hypertension (PDHYPER), defined as any increase of systolic BP (SBP) >10mm, Hg above the predialysis value, the associated factors and its role in cardiovascular (CV) mortality.

PATIENTS AND METHODS

In this observational study, we assessed dialysis associated changes in BP in 4,292 hemodialysis (HD) patients over 1 month (51,504 sessions). We compared the clinical characteristics of the patients with stable BP values during the HD session with those with PDHYPER. We also assessed the impact of PDHYPER on CV mortality.

RESULTS

A total of 994 (23.1%) patients had PDHYPER. Patients with PDHYPER were more likely to be hypertesive, older, have a shorter dialysis vintage, be male, have lower SBP, lower changes in weight during HD, and receive more antihypertensive medications. These predictive factors were shown to be associated with an interaction between weight loss and dialysis, suggesting a volume-related mechanism in its pathogenesis. PDHYPER was also associated with CV mortality.

CONCLUSIONS

In our study on a large Italian cohort of dialysis patients, the prevalence of PDHYPER was higher than what was previously reported and is a significant risk factor for CV mortality in dialysis patients. The pathogenesis is multifactorial but hypertensive state, antihypertensive medications, and extracellular volume expansion appear to play a major role.

We Hold Antihypertensives Prior To Dialysis

Hypertension is the most common complication of end-stage renal disease and chronic hemodialysis and yet, only a third of these patients have adequately controlled blood pressures. Pathogenesis of hypertension in this population is complex and multifactorial and therefore poses numerous treatment challenges. Furthermore, it is common practice among nephrologists to withhold antihypertensives prior to a hemodialysis procedure due to concerns for intradialytic hypotension (IDH). Intradialytic hypertension (ID-HTN) is an increasingly recognized phenomenon and although less common than IDH, portends poor cardiovascular prognosis as well as reflects higher hypertension burden in the dialysis population. Withholding antihypertensives prior to dialysis routinely in patients may worsen interdialytic blood pressure control as well as increase the prevalence of euvolemic ID-HTN. It may also increase the risk of cardiac arrhythmias and further compromise hemodynamic stability during dialysis. In such situations, predialysis administration of antihypertensive is appropriate and necessary and drug choice should be based on the patient's comorbidities, pharmacokinetics of the drug and its dialyzability.

Comparison of Ambulatory Blood Pressure Patterns in Patients With Intradialytic Hypertension and Hemodialysis Controls

Background/Aims

Intradialytic hypertension (IH) patients have higher mortality risk than other hemodialysis patients and have been shown to have higher ambulatory blood pressure (BP). We hypothesized that interdialytic BP patterns would differ in IH patients and hypertensive hemodialysis controls.

Methods

We consecutively screened hemodialysis patients at our university-affliated units. Based on pre and post-HD BP measurements during the prior 2 week period, we identified IH patients and demographically matched hemodialysis controls. We measured ambulatory interdialytic BP, fow-mediated vasodilation, and intradialytic endothelin-1 (ET-1). Using linear mixed-models, we compared BP slopes during the following intervals: 1–24 hours post-dialysis, 25–44 hours post-dialysis, and 1–44 hours post-dialysis.

Results

There were 25 case subjects with IH and 24 controls. Systolic BP during hours 1–44, 1–24, and 25–44 were 143.1 (16.5), 138.0 (21.2), and 150.8 (22.3) mmHg in controls. For IH subjects, they were 155.4 (14.2), 152.7 (22.8), and 156.5 (20.8) mmHg (p=0.008, 0.02, 0.4). In controls, the slopes were +0.6, +0.6, and +0.4 mmHg/hr. In IH subjects, they were +0.1, −0.3, and +0.3 mmHg/hr. The IH 1–24 hour slope differed from the IH 25–44 hour slope (p=0.001) and the control 1–24 hour slope (p=0.002). The change in ET-1 from pre to post dialysis was 0.5 (1.5) pg/mL in controls and 1.0 (2.3) pg/mL in IH patients (p=0.4). In a univariate model, there was an association with screening BP and BP slope (p=0.002 for controls and p=0.1 for IH patients).

Conclusions

Interdialytic BP patterns differ in IH patients and hemodialysis controls. The elevated post dialysis blood pressure persists for many hours in IH patients contributing to the overall increased BP burden.

Mechanisms and Treatment of Intradialytic Hypertension

BACKGROUND

Intradialytic hypertension is a condition where there is an increase in blood pressure (BP) from pre- to post-hemodialysis; this condition has been recently identified as an independent mortality risk factor in hypertensive hemodialysis patients. The mechanisms and management of intradialytic hypertension have been explored in numerous research studies over the past few years.

SUMMARY

Patients with intradialytic hypertension have been found to be more chronically volume overloaded compared to other hemodialysis patients, although no causal role has been established. Patients with intradialytic hypertension have intradialytic vascular resistance surges that likely explain the BP increase during dialysis. Acute intradialytic changes in endothelial cell function have been proposed as etiologies for the increase in vascular resistance, although it is unclear if endothelin-1 or some other vasoconstrictive peptide is responsible. There is an association between dialysate to serum sodium gradients and BP increase during dialysis in patients with intradialytic hypertension, although it is unclear if this is related to endothelial cell activity or acute osmolar changes. In addition to probing the dry weight of patients with intradialytic hypertension, other management strategies include lowering dialysate sodium and changing antihypertensives to include carvedilol or other poorly dialyzed antihypertensives.

KEY MESSAGES

Hemodialysis patients with intradialytic hypertension have an increased mortality risk compared to patients with modest decreases in BP during dialysis. Intradialytic hypertension is associated with extracellular volume overload in addition to acute increases in vascular resistance during dialysis. Management strategies should include reevaluation of dry weight and modification of both the dialysate prescription and medication prescription.

Intradialytic Blood Pressure Abnormalities: The Highs, The Lows and All That Lies Between

BACKGROUND

Frequent blood pressure (BP) measurements are necessary to ensure patient safety during hemodialysis treatments. Intradialytic BPs are not optimal tools for hypertension diagnosis and cardiovascular risk stratification, but they do have critical clinical and prognostic significance. We present evidence associating intradialytic BP phenomena including fall, rise and variability with adverse clinical outcomes and review related pathophysiologic mechanisms and potential management strategies.

SUMMARY

Observational studies demonstrate associations between intradialytic hypotension, hypertension and BP variability and mortality. Lack of consensus regarding diagnostic criteria has hampered data synthesis, and prospective studies investigating optimal management strategies for BP phenomena are lacking. Mechanistic data suggest that cardiac, gut, kidney and brain ischemia may lie on the causal pathway between intradialytic hypotension and mortality, and endothelial cell dysfunction, among other factors, may be an important mediator of intradialytic hypertension and adverse outcomes. These plausible pathophysiologic links present potential therapeutic targets for future inquiry. The phenomenon of intradialytic BP variability has not been adequately studied, and practical clinical measures and treatment strategies are lacking.

KEY MESSAGES

Intradialytic BP phenomena have important prognostic bearing. Clinical practice guidelines for both intradialytic hypotension and hypertension exist, but their underlying evidence is weak overall. Further research is needed to develop consensus diagnostic criteria for intradialytic hypotension, hypertension and BP variability and to elucidate optimal treatment and prevention strategies for each BP manifestation.

Higher visit-to-visit intra-dialytic blood pressure is associated with the progression of aortic valve stenosis in chronic hemodialysis patients

Aortic valve stenosis (AS) is a frequent complication contributing to poor prognosis in chronic hemodialysis (CHD) patients. High blood pressure (BP) is known to be associated with AS progression in the general population. In CHD patients, however, BP varies during and between hemodialysis sessions with ultrafiltration volume or inter-dialytic weight gain; therefore it is difficult to characterize the BP status with a conventional single measurement. Our purpose was to clarify the BP variables affecting AS progression in CHD patients. We retrospectively enrolled 32 consecutive CHD patients with AS [aortic valve area (AVA), 1.3 ± 0.3 cm(2); mean age 69 ± 8 years] who had serial transthoracic echocardiographic studies at least 6 months apart (mean 23 ± 9 months). AS progression was evaluated using absolute reduction in AVA per year. Pre-dialytic and intra-dialytic (every hour during sessions) BPs throughout the 3 consecutive visits were used to determine each patient's BP status. We calculated the mean values of pre-dialytic and intra-dialytic BPs and their variability. In univariate analysis, mean visit-to-visit pre-dialytic and intra-dialytic BP were associated with AS progression, whereas all variables of BP variability were not. Multiple regression analysis indicated that only mean visit-to-visit intra-dialytic systolic and diastolic BP remained independently associated with AS progression after adjustment for age, sex, hypertension, hypercholesterolemia, diabetes mellitus, and serum parathyroid hormone (p < 0.05). Although BP regulation in CHD patients is complex and multifactorial, mean visit-to-visit intra-dialytic BP was independently associated with AS progression. Prospective studies are necessary before considering intra-dialytic BP as a potential target for therapy.

Classifying individuals based on a densely captured sequence of vital signs: An example using repeated blood pressure measurements during hemodialysis treatment

Electronic Health Records (EHRs) present the opportunity to observe serial measurements on patients. While potentially informative, analyzing these data can be challenging. In this work we present a means to classify individuals based on a series of measurements collected by an EHR. Using patients undergoing hemodialysis, we categorized people based on their intradialytic blood pressure. Our primary criteria were that the classifications were time dependent and independent of other subjects. We fit a curve of intradialytic blood pressure using regression splines and then calculated first and second derivatives to come up with four mutually exclusive classifications at different time points. We show that these classifications relate to near term risk of cardiac events and are moderately stable over a succeeding two-week period. This work has general application for analyzing dense EHR data.

Antihypertensive Medications in End-Stage Renal Disease

Hypertension is almost universal in end-stage renal disease (ESRD) and contributes to the substantial cardiovascular (CV) morbidity and mortality observed in these patients. The management of blood pressure (BP) in ESRD is complicated by a number of factors, including missed dialysis treatments, intradialytic changes in BP, medication removal with dialysis, and poor correlation of BPs obtained in the dialysis unit with those at home and with CV outcomes. Control of extracellular volume with ultrafiltration and dietary sodium restriction represents the principal strategy to manage hypertension in ESRD, and antihypertensive medications are subsequently added if this strategy is inadequate. While reduction in BP with medication improves CV outcomes, few head-to-head clinical trials have been performed to firmly establish the superiority of one antihypertensive medication class over another. Therefore, individualization of therapy is necessary, and patient comorbidities must be considered. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers are reasonable first-line agents for most patients. ACE inhibitors and ARBs exert cardioprotective effects that are independent of BP reduction. Medications that are removed with dialysis may be preferred in patients who are prone to develop intradialytic hypotension. Intradialytic hypertension can be managed with challenging the patient's dry weight and using nondialyzable medications. Within a class of antihypertensive medications, there may be large variability in drug removal with dialysis, which must be considered upon medication selection. Studies demonstrate that even thrice-weekly dosing of medication after dialysis has robust BP-lowering effects, which may be a useful regimen in nonadherent patients.

Ischemic brain injury in hemodialysis patients: which is more dangerous, hypertension or intradialytic hypotension?

Abnormalities of cognitive function and high levels of depression incidence are characteristic of hemodialysis patients. Although previously attributed to the humoral effects of uremia, it is becoming increasingly appreciated that many elements of the overall disease state in CKD patients contribute to functional disturbances and physical brain injury. These factors range from those associated with the underlying primary diseases (cardiovascular, diabetes etc.) to those specifically associated with the requirement for dialysis (including consequences of the hemodialysis process itself). They are, however, predominantly ischemic threats to the integrity of brain tissue. These evolving insights are starting to allow nephrologists to appreciate the potential biological basis of dependency and depression in our patients, as well as develop and test new therapeutic approaches to this increasingly prevalent and important issue. This review aims to summarize the current understanding of brain injury in this setting, as well as examine recent advances being made in the modification of dialysis-associated brain injury.

Intradialytic hypotension and cardiac remodeling: a vicious cycle

Hemodynamic instability during hemodialysis is a common but often underestimated issue in the nephrologist practice. Intradialytic hypotension, namely, a decrease of systolic or mean blood pressure to a certain level, prohibits the safe and smooth achievement of ultrafiltration and solute removal goal in chronic dialysis patients. Studies have elucidated the potential mechanisms involved in the development of Intradialytic hypotension, including excessive ultrafiltration and loss of compensatory mechanisms for blood pressure maintenance. Cardiac remodeling could also be one important piece of the puzzle. In this review, we intend to discuss the role of cardiac remodeling, including left ventricular hypertrophy, in the development of Intradialytic hypotension. In addition, we will also provide evidence that a bidirectional relationship might exist between Intradialytic hypotension and left ventricular hypertrophy in chronic dialysis patients. A more complete understanding of the complex interactions in between could assist the readers in formulating potential solutions for the reduction of both phenomena.

Hemodialysis immediately after cardiac catheterization is a risk factor for intradialytic hypotension

Many hemodialysis clinicians have noticed that patients frequently develop intradialytic hypotension (IDH) immediately after cardiac catheterization (CC). However, precise data about the incidence of IDH immediately after CC are scarce. This study involved a single-center, retrospective, cross-sectional design. We reviewed the medical records of all HD patients who underwent CC between January 2009 and March 2012 at Hiroshima Prefectural Hospital. IDH was defined as a fall of systolic blood pressure of more than 20 mm Hg or a fall of mean blood pressure of more than 10 mm Hg, with symptoms according to the K/DOQI criteria. Data on a total of 112 patients were obtained: 64 patients commenced HD immediately after CC (IA group) and 48 patients underwent HD on the day after CC (ND group). The overall incidence of IDH was 34% (38/112). The incidence of IDH was significantly higher in the IA group than in the ND group (27/64, 42% vs. 11/48, 23%; P < 0.05). Multivariate logistic regression analysis showed that IA (odds ratio, 5.39; 95% confidence interval, 1.76 to 16.49; P < 0.01), coronary stenosis (odds ratio, 4.16; 95% confidence interval, 1.49 to 11.64; P < 0.05) were independently associated with IDH. This study revealed that HD immediately after CC is associated with a higher incidence of IDH. Clinicians should consider that HD following CC be scheduled for the next day, especially in patients with coronary stenosis.

Assessment and management of hypertension in patients on dialysis

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.

Increased postdialysis systolic blood pressure is associated with extracellular overhydration in hemodialysis outpatients

Recently, intradialytic hypertension was reported to be associated with increased mortality for hemodialysis patients. To determine whether volume status plays a role in dialysis-associated hypertension, we prospectively audited 531 patients that had volume assessments measured by multiple-frequency bioelectrical impedance during their midweek dialysis session. Mean pre- and postdialysis weights were 73.2 vs 71.7 kg, and systolic blood pressures (SBPs) 140.5 vs. 130.3 mm Hg, respectively. Patients were divided into groups based on a fall in SBP of 20 mm Hg or more (32%), an increased SBP of 10 mm Hg or more (18%), and a stable group (50%). There were no differences in patient demographics, dialysis prescriptions, predialysis weight, total body (TBW), and extracellular (ECW) and intracellular water (ICW). However, the change in weight was significantly less in the increased blood pressure group (1.01 kg vs. stable 1.65, and 1.7 hypotensive). The ratio of ECW to TBW was significantly higher in the increased blood pressure group, particularly post dialysis (39.1 vs. stable 38.7% and fall in blood pressure group 38.7%). ECW overhydration was significantly greater in the increased blood pressure group post dialysis (0.7 (0.17 to 1.1) vs. stable 0.39 (-0.2 to 0.95) and fall in blood pressure group 0.38 (-0.19 to 0.86) liter). We found that patients who had increased blood pressure post dialysis had greater hydration status, particularly ECW. Thus, patients who increase their blood pressure post dialysis should have review of target weight, consideration of lowering the post-dialysis weight, and may benefit from increasing dialysis session time or frequency.

Peri-dialytic hypertension and hypotension: another U-shaped BP-outcome association

Park et al. performed a retrospective analysis of a large hemodialysis cohort to describe the relationship between pre- to postdialysis changes in BP and mortality. Their study demonstrated adverse outcomes associated both with large decreases and with any increase in blood pressure pre- to postdialysis. Although limitations exist in this analysis, which lacked intradialytic blood pressure measurements, the results support the ongoing concern about the potential adverse hemodynamic stress associated with conventional three-times-weekly hemodialysis.

Hypertension in hemodialysis patients: an opinion-based update

Hypertension is highly prevalent in hemodialysis patients but its management remains a matter of debate. In this review, we discuss the observational studies on the association of blood pressure with outcomes, measurement of blood pressure in hemodialysis patients and present an opinion-based approach to treating hypertension.

Predialysis systolic BP variability and outcomes in hemodialysis patients

BP variability (BPV) is an important predictor of outcomes in the general population, but its association with clinical outcomes in hemodialysis patients is not clear. We identified 11,291 patients starting dialysis in 2003-2008 and followed them through December 31, 2008 (median=22 months). Predialysis systolic BPV was assessed over monthly intervals. Outcomes included factors associated with BPV, mortality (all-cause and cardiovascular), and first cardiovascular event (cardiovascular death or hospitalization). Patients' mean age was 62 years, 55% of patients were men, and 58% of patients were white. Modifiable factors associated with higher BPV included obesity, higher calcium-phosphate product levels, and lower hemoglobin concentration; factors associated with lower BPV included greater fluid removal, achievement of prescribed dry weight during dialysis, higher hemoglobin concentration, and antihypertensive regimens without β-blockers or renin-angiotensin system blocking agents. In total, 3200 deaths occurred, including 1592 cardiovascular deaths. After adjustment for demographics, comorbidities, and clinical factors, higher predialysis BPV was associated with increased risk of all-cause mortality (hazard ratio [HR], 1.18; 95% confidence interval [95% CI] per 1 SD increase in BPV, 1.13 to 1.22), cardiovascular mortality (HR, 1.18; 95% CI, 1.12 to 1.24), and first cardiovascular event (HR, 1.11; 95% CI, 1.07 to 1.15). Results were similar when BPV was categorized in tertiles and patients were stratified by baseline systolic BP. In summary, predialysis systolic BPV is an important, potentially modifiable risk factor for death and cardiovascular outcomes in incident hemodialysis patients. Studies of BP management in dialysis patients should focus on both absolute BP and BPV.

Near-term prediction of sudden cardiac death in older hemodialysis patients using electronic health records

BACKGROUND AND OBJECTIVES

Sudden cardiac death is the most common cause of death among individuals undergoing hemodialysis. The epidemiology of sudden cardiac death has been well studied, and efforts are shifting to risk assessment. This study aimed to test whether assessment of acute changes during hemodialysis that are captured in electronic health records improved risk assessment.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data were collected from all hemodialysis sessions of patients 66 years and older receiving hemodialysis from a large national dialysis provider between 2004 and 2008. The primary outcome of interest was sudden cardiac death the day of or day after a dialysis session. This study used data from 2004 to 2006 as the training set and data from 2007 to 2008 as the validation set. The machine learning algorithm, Random Forests, was used to derive the prediction model.

RESULTS

In 22 million sessions, 898 people between 2004 and 2006 and 826 people between 2007 and 2008 died on the day of or day after a dialysis session that was serving as a training or test data session, respectively. A reasonably strong predictor was derived using just predialysis information (concordance statistic=0.782), which showed modest but significant improvement after inclusion of postdialysis information (concordance statistic=0.799, P<0.001). However, risk prediction decreased the farther out that it was forecasted (up to 1 year), and postdialytic information became less important.

CONCLUSION

Subtle changes in the experience of hemodialysis aid in the assessment of sudden cardiac death and are captured by modern electronic health records. The collected data are better for the assessment of near-term risk as opposed to longer-term risk.

Hemodynamic and pathophysiological characteristics of intradialytic blood pressure elevation in patients with end-stage renal disease

An increase in systolic blood pressure (SBP) after hemodialysis (intradialytic-HTN) is associated with adverse outcomes in patients on regular hemodialysis. However, the hemodynamic and Doppler echocardiographic characteristics of intradialytic-HTN and its impact on clinical outcomes are unclear. A retrospective analysis of 84 patients (45 men, 70±9 years) stratified into three groups on the basis of SBP response from pre- to post-hemodialysis: GHTN (intradialytic-HTN, SBP increase 10 mm Hg), GDROP<15 mm Hg (SBP drop <15 mm Hg), and GDROP15 mm Hg (SBP drop 15 mm Hg). Hemodynamic and echocardiographic assessments were performed pre- and post-hemodialysis, and patients were followed for 41±17 months. GHTN had higher blood glucose and lower baseline SBP, serum potassium and total cholesterol. Cardiothoracic ratio was smaller, and peak early diastolic mitral annular velocity (E') was lower in GHTN. During hemodialysis, SBP and diastolic blood pressure increased only in GHTN. After hemodialysis, left ventricular (LV) filling pressure (E/E' ratio) decreased only in GDROP15 mm Hg, resulting in a higher E/E' ratio in GHTN than GDROP15 mm Hg. Multivariate logistic regression analysis revealed a positive correlation between blood glucose and intradialytic-HTN, whereas cardiothoracic ratio, pre-hemodialysis SBP and the change in E/E' ratio with hemodialysis were negatively related to intradialytic-HTN. During follow-up, GHTN had more cardiovascular deaths than GDROP15 mm Hg (P=0.03). Multivariate Cox regression analysis showed that lower serum potassium and previous coronary artery disease, but not intradialytic-HTN, were associated with cardiovascular deaths. A higher LV afterload and elevated filling pressures after hemodialysis, indicative of increased cardiovascular stiffening and impaired diastolic filling, may contribute in part to an increased cardiovascular burden in patients with intradialytic-HTN.