Dry-Weight Reduction in Hypertensive Hemodialysis Patients (DRIP): A Randomized, Controlled Trial
Open accessAbstract
Volume excess is thought to be important in the pathogenesis of hypertension among hemodialysis patients. To determine whether additional volume reduction will result in improvement in blood pressure (BP) among hypertensive patients on hemodialysis and to evaluate the time course of this response, we randomly assigned long-term hypertensive hemodialysis patients to ultrafiltration or control groups. The additional ultrafiltration group (n=100) had the dry weight probed without increasing time or duration of dialysis, whereas the control group (n=50) only had physician visits. The primary outcome was change in systolic interdialytic ambulatory BP. Postdialysis weight was reduced by 0.9 kg at 4 weeks and resulted in −6.9 mm Hg (95% CI: −12.4 to −1.3 mm Hg; P =0.016) change in systolic BP and −3.1 mm Hg (95% CI: −6.2 to −0.02 mm Hg; P =0.048) change in diastolic BP. At 8 weeks, dry weight was reduced 1 kg, systolic BP changed −6.6 mm Hg (95% CI: −12.2 to −1.0 mm Hg; P =0.021), and diastolic BP changed −3.3 mm Hg (95% CI: −6.4 to −0.2 mm Hg; P =0.037) from baseline. The Mantel-Hanzel combined odds ratio for systolic BP reduction of ≥10 mm Hg was 2.24 (95% CI: 1.32 to 3.81; P =0.003). There was no deterioration seen in any domain of the kidney disease quality of life health survey despite an increase in intradialytic signs and symptoms of hypotension. The reduction of dry weight is a simple, efficacious, and well-tolerated maneuver to improve BP control in hypertensive hemodialysis patients. Long-term control of BP will depend on continued assessment and maintenance of dry weight.
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During the last two decades, HBPM has been used increasingly in clinical hypertension research.
“During the last two decades, HBPM has been used increasingly in clinical hypertension research [17,155,267–273].”
From Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension (2021) · cites this paper as [273]
The Introduction and Methods describe interdialytic ambulatory blood pressure monitoring in a hemodialysis trial, not home blood pressure monitoring (HBPM). Our copy does not discuss whether HBPM use in clinical hypertension research increased over the preceding two decades (searched for HBPM, home monitoring, and increasing use). (LLM, conf=0.78)
Experimental — accuracy not yet measuredDuring the last two decades, HBPM has been used increasingly in clinical hypertension research.
“During the last two decades, HBPM has been used increasingly in clinical hypertension research [17,155,267–273].”
From Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension (2021) · cites this paper as [269]
The Methods describe 44-hour ambulatory blood pressure monitoring in this hemodialysis trial, not home blood pressure monitoring (HBPM). A search for HBPM and for increasing use in hypertension research found no passage in our copy addressing that trend. (LLM, conf=0.75)
Experimental — accuracy not yet measured
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Reilly, R. (2014) · American Society of Nephrology. Clinical Journal · doi:10.2215/cjn.09930913 · Cited by 70
Controversies and problems of volume control and hypertension in haemodialysis.
Ok, E., Aşcı, G., Chazot, C., Ozkahya, M., & Mees, E. J. D. (2016) · The Lancet · doi:10.1016/s0140-6736(16)30389-0 · Cited by 68 · see citing works
Epidemiology, diagnosis and management of hypertension among patients on chronic dialysis
Georgianos, P., & Agarwal, R. (2016) · Nature Reviews Nephrology · doi:10.1038/nrneph.2016.129 · Cited by 64 · see citing works
Self-citationMechanisms and Treatment of Intradialytic Hypertension
Buren, P. V. V., & Inrig, J. (2016) · Blood Purification · doi:10.1159/000441313 · Cited by 64
Lai, A. C., Bienstock, S. W., Sharma, R., Skorecki, K., Beerkens, F., Samtani, R., Coyle, A., Kim, T., Baber, U., Camaj, A., et al. (2021) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2021.01.028 · Cited by 62 · see citing works
Resistant Hypertension and Obstructive Sleep Apnea in the Setting of Kidney Disease
Abdel-Kader, K., Dohar, S., Shah, N., Jhamb, M., Reis, S., Strollo, P., Buysse, D. J., & Unruh, M. (2012) · Journal of Hypertension · doi:10.1097/hjh.0b013e328351d08a · Cited by 61 · see citing works
Zhou, Y.-L., Liu, J., Sun, F., Ma, L.-J., Han, B., Shen, Y., & Cui, T.-G. (2010) · American Journal of Nephrology · doi:10.1159/000315135 · Cited by 61 · see citing works
“Although the reduction of DW is documented to be a simple and efficacious maneuver to improve blood pressure (BP) control in hypertensive HD patients [”
BackgroundBP in Dialysis: Results of a Pilot Study.
Miskulin, D., Gassman, J., Schrader, R. M., Gul, A., Jhamb, M., Ploth, D., Negrea, L., Kwong, R., Levey, A., Singh, A., et al. (2017) · Journal of the American Society of Nephrology · doi:10.1681/asn.2017020135 · Cited by 60 · see citing works
Canaud, B., Kooman, J., Selby, N., Taal, M., Francis, S., Kopperschmidt, P., Maierhofer, A., Kotanko, P., & Titze, J. (2019) · Kidney International · doi:10.1016/j.kint.2018.09.024 · Cited by 58 · see citing works
Zaloszyc, A., Schaefer, B., Schaefer, F., Krid, S., Salomon, R., Niaudet, P., Schmitt, C., & Fischbach, M. (2013) · Pediatric nephrology (Berlin, West) · doi:10.1007/s00467-013-2540-6 · Cited by 56
“However, this process of “probing dry weight” is not effective for reducing hypertension in all cases and may additionally lead to dialytic morbidity and even sometimes mortality, especially in the case of volume-independent BP [10–15].”
BackgroundDiagnosis and Management of Pulmonary Hypertension in Patients With CKD
Walther, C., Nambi, V., Hanania, N., & Navaneethan, S. (2020) · American Journal of Kidney Diseases · doi:10.1053/j.ajkd.2019.12.005 · Cited by 55
B-type natriuretic peptide is not a volume marker among patients on hemodialysis.
Agarwal, R. (2013) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gft054 · Cited by 55 · see citing works
“Accordingly, the hypothesis that BNP is a marker of volume among hypertensive hemodialysis patients upon probing dry weight was tested as a prespecified analysis of the dry-weight reduction in hypertensive hemodialysis patients (DRIP) trial [22].”
MethodSelf-citationVolume-associated ambulatory BP patterns in hemodialysis patients
Agarwal, R. (2009) · HYPERTENSION · doi:10.1161/hypertensionaha.109.136366 · Cited by 54 · see citing works
“Vasodilators 9 (19) 16 (16) ACE inhibitors 24 (50) 51 (53) Angiotensin receptor blockers 4 (8) 19 (20)”
Self-citationHypertension in peritoneal dialysis patients: epidemiology, pathogenesis, and treatment.
Ortega, L., & Materson, B. (2011) · Journal of the American Society of Hypertension : JASH · doi:10.1016/j.jash.2011.02.004 · Cited by 53
Heart Failure in End-Stage Kidney Disease: Pathophysiology, Diagnosis, and Therapeutic Strategies.
Rangaswami, J., & McCullough, P. (2018) · Seminars in Nephrology · doi:10.1016/j.semnephrol.2018.08.005 · Cited by 52 · see citing works
Assessment and Management of Hypertension among Patients on Peritoneal Dialysis.
Vaios, V., Georgianos, P., Liakopoulos, V., & Agarwal, R. (2018) · American Society of Nephrology. Clinical Journal · doi:10.2215/cjn.07480618 · Cited by 52
“In the Dry Weight Reduction in Hypertensive Hemodialysis Patients trial (24), dry weight reduction of 0.”
BackgroundSelf-citationAgarwal, R., & Light, R. (2009) · American Journal of Kidney Diseases · doi:10.1053/j.ajkd.2009.03.018 · Cited by 52 · see citing works
Self-citationWong, J., Vilar, E., Davenport, A., & Farrington, K. (2015) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gfv231 · Cited by 51
“Although the Tassin group [74] and a recent randomized controlled trial showed that increasing ultrafiltration improved blood pressure control, continuous probing for the optimum dry weight by systematic increments in ultrafiltration [75] may lead to an increased incidence of intradialytic hypotension.”
Dry weight targeting: The art and science of conventional hemodialysis
Ohashi, Y., Sakai, K., Hase, H., & Joki, N. (2018) · Seminars in dialysis · doi:10.1111/sdi.12721 · Cited by 49 · see citing works
“shown to be associated with reduction in blood pressure and cardiac hypertrophy.(12,38,45,46) Meanwhile, there is a risk to dry weight reduction that should be considered.”
BackgroundDialysis adequacy today: a European perspective.
Locatelli, F., & Canaud, B. (2012) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gfs184 · Cited by 49 · see citing works
Pharmacotherapy of Hypertension in Chronic Dialysis Patients.
Georgianos, P., & Agarwal, R. (2016) · American Society of Nephrology. Clinical Journal · doi:10.2215/cjn.00870116 · Cited by 48 · see citing works
“The Dry-Weight Reduction in Hemodialysis Patients (DRIP) trial showed the net BP–lowering effect of probing of dry weight in patients on hemodialysis who are hypertensive (14).”
BackgroundSelf-citationChen, H.-S., Chang, Y.-C., Hsieh, M.-H., Tseng, F.-L., Lin, C.-C., Wu, T.-K., Chen, H.-P., Hung, S.-H., Chiu, H., Lee, C.-C., et al. (2016) · International Urology and Nephrology · doi:10.1007/s11255-016-1415-8 · Cited by 46
Pathogenesis and management of hypertension after kidney transplantation
Chatzikyrkou, C., Menne, J., Gwinner, W., Schmidt, B., Lehner, F., Blume, C., Schwarz, A., Haller, H., & Schiffer, M. (2011) · Journal of Hypertension · doi:10.1097/hjh.0b013e32834bd1e7 · Cited by 46 · see citing works
Chazot, C., Vo-Van, C., Zaoui, E., Vanel, T., Hurot, J., Lorriaux, C., Mayor, B., Deléaval, P., & Jean, G. (2011) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gfq804 · Cited by 46
Special situations: Intradialytic hypertension/chronic hypertension and intradialytic hypotension
Buren, P. N. V., & Inrig, J. K. (2017) · Seminars in Dialysis · doi:10.1111/sdi.12631 · Cited by 51 · see citing works
“The Dry Weight Intervention in Hypertensive Hemodialysis Patients (DRIP) Study Identified that more intensive ultrafiltration could lower both dialysis unit BP as well as ambulatory BP in as little as 4 weeks.(36) The risks of overly aggressive ultrafiltration and ultrafiltration rate were explained in the intradialyt…”
MethodHypertension and hemodialysis: pathophysiology and outcomes in adult and pediatric populations
Buren, P. V. V., & Inrig, J. (2011) · Pediatric nephrology (Berlin, West) · doi:10.1007/s00467-011-1775-3 · Cited by 43 · see citing works
“Gradual dry weight reduction leads to improved ambulatory BP in hypertensive HD patients [24].”
BackgroundMethodAgarwal, R. (2010) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gfq171 · Cited by 43 · see citing works
“For example, in the dry-weight reduction in hypertensive haemodialysis patients (DRIP) study [16], home BP could detect the fall in BP as well as ambulatory BPs [17].”
BackgroundSelf-citationAntlanger, M., Josten, P., Kammer, M., Exner, I., Lorenz-Turnheim, K., Eigner, M., Paul, G., Klauser-Braun, R., Sunder-Plassmann, G., Säemann, M., et al. (2017) · BMC Nephrology · doi:10.1186/s12882-017-0639-x · Cited by 42
Setting the Dry Weight and Its Cardiovascular Implications
Sinha, A. D., & Agarwal, R. (2017) · Seminars in dialysis · doi:10.1111/sdi.12624 · Cited by 42
Self-citationHow should we manage adverse intradialytic blood pressure changes?
Santos, S., Peixoto, A., & Perazella, M. (2012) · Advances in Chronic Kidney Disease · doi:10.1053/j.ackd.2012.03.003 · Cited by 42 · see citing works
“This was initially suggested by observations that intensive UF applied to 7 patients with IDHTN resulted in restoration of euvolemia and normalization of intradialytic BP.63 An interesting hypothesis is that individuals with left ventricular dilatation due to volume overload respond to the UF-induced reduction in end-…”
BackgroundInfluentialProbing Dry-Weight Improves Left Ventricular Mass Index
Agarwal, R., Bouldin, J. M., Light, R., & Garg, A. (2010) · American Journal of Nephrology · doi:10.1159/000326235 · Cited by 42
“We have previously demonstrated that probing dry-weight can improve interdialytic hypertension within 4 weeks [”
BackgroundSelf-citationHome and ambulatory blood pressure monitoring in chronic kidney disease
Agarwal, R. (2009) · Current opinion in nephrology and hypertension · doi:10.1097/mnh.0b013e3283319b9d · Cited by 41 · see citing works
Self-citationSymptomatic Intradialytic Hypotension and Mortality: An Opinionated Review
Henderson, L. W. (2012) · Seminars in dialysis · doi:10.1111/j.1525-139x.2012.01068.x · Cited by 40
Diagnosis and treatment of hypertension in dialysis patients: a systematic review
Kim, I., Kim, S., Yoo, T., & Kim, J.-K. (2023) · Clinical Hypertension · doi:10.1186/s40885-023-00240-x · Cited by 39 · see citing works
“If appropriate, the target DW should be adjusted before antihypertensive agents are added, because gradual DW reduction can normalize the BP or make BP control easier [73–76].”
BackgroundThe Optimal Blood Pressure Target in Different Dialysis Populations
Jhee, J., Park, J., Kim, H., Kee, Y. K., Park, J., Han, S., Yang, C.-W., Kim, N.-H., Kim, Y. S., Kang, S.-W., et al. (2018) · Scientific Reports · doi:10.1038/s41598-018-32281-w · Cited by 39 · see citing works
Sebastian, S., Filmalter, C., Harvey, J., & Chothia, M. (2016) · Clinical Kidney Journal · doi:10.1093/ckj/sfw052 · Cited by 37
“Management of this condition is focussed on fluid removal over a sustained period of time, as demonstrated in the dryweight reduction in hypertensive hemodialysis patients trial [29].”
BackgroundResistant hypertension and the neglected antihypertensive: sodium restriction.
Agarwal, R. (2012) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gfs384 · Cited by 37 · see citing works
“The volume control strategy has been tested in one randomized controlled trial [21].”
MethodSelf-citationUltrafiltration Rate Thresholds in Maintenance Hemodialysis: An NKF-KDOQI Controversies Report.
Kramer, H., Yee, J., Weiner, D., Bansal, V., Choi, M. J., Brereton, L., Berns, J., Samaniego-Picota, M., Scheel, P., & Rocco, M. (2016) · American Journal of Kidney Diseases · doi:10.1053/j.ajkd.2016.06.010 · Cited by 35
Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of Japanese Society of Dialysis Therapy)
Ito, Y., Ryuzaki, M., Sugiyama, H., Tomo, T., Yamashita, A., Ishikawa, Y., Ueda, A., Kanazawa, Y., Kanno, Y., Itami, N., et al. (2021) · Renal Replacement Therapy · doi:10.1186/s41100-021-00348-6 · Cited by 33 · see citing works
Georgianos, P., Pikilidou, M., Liakopoulos, V., Balaskas, E., & Zebekakis, P. (2018) · Hypertension Research · doi:10.1038/s41440-018-0025-5 · Cited by 33 · see citing works
Frequency of intradialytic hypotensive episodes: old problem, new insights.
Rocha, A., Sousa, C., Teles, P., Coelho, A., & Xavier, E. (2015) · Journal of the American Society of Hypertension : JASH · doi:10.1016/j.jash.2015.07.007 · Cited by 33
Management of hypertension in hemodialysis patients
Ram, C., & Fenves, A. (2009) · Current Hypertension Reports · doi:10.1007/s11906-009-0049-y · Cited by 33 · see citing works
“Simply achieving dry weight may not suffi ce for some patients on hemodialysis [41, 42 ].”
Background3 Tesla 23Na Magnetic Resonance Imaging During Acute Kidney Injury.
Hammon, M., Grossmann, S., Linz, P., Seuss, H., Hammon, R., Rosenhauer, D., Janka, R., Cavallaro, A., Luft, F., Titze, J., et al. (2017) · Academic Radiology · doi:10.1016/j.acra.2017.03.012 · Cited by 32 · see citing works
Penne, E., Levin, N., & Kotanko, P. (2010) · Blood Purification · doi:10.1159/000317124 · Cited by 32 · see citing works
“Identifying these patients is of clinical importance, since they are most likely to benefit from interventions. It has been shown that decreasing the post-dialysis target weight in hypertensive HD patients leads after 4 weeks to significant blood pressure reductions of a similar magnitude to that achieved with a singl…”
ResultVolume Overload in Dialysis: The Elephant in the Room, No One Can See
Agarwal, R. (2013) · American Journal of Nephrology · doi:10.1159/000353107 · Cited by 31 · see citing works
Self-citationCuratola, G., Bolignano, D., Rastelli, S., Caridi, G., Tripepi, R., Tripepi, G., Politi, R., Catalano, F., Delfino, D., Ciccarelli, M., et al. (2011) · JN. Journal of Nephrology (Milano. 1992) · doi:10.5301/jn.2011.7735 · Cited by 31
Pathophysiology and Implications of Intradialytic Hypertension
Buren, P. V. V. (2017) · Current opinion in nephrology and hypertension · doi:10.1097/mnh.0000000000000334 · Cited by 30
Brain Natriuretic Peptide Is a Marker of Fluid Overload in Incident Hemodialysis Patients
Chazot, C., Rozes, M., Vo-Van, C., Deléaval, P., Hurot, J., Lorriaux, C., Mayor, B., Zaoui, E., & Jean, G. (2017) · CardioRenal Medicine · doi:10.1159/000471815 · Cited by 30
Shorter delivered dialysis times associate with a higher and more difficult to treat blood pressure.
Tandon, T., Sinha, A. D., & Agarwal, R. (2013) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gfs597 · Cited by 30
Self-citationJun, M., Lv, J., Perkovic, V., & Jardine, M. (2011) · Therapeutic Advances in Chronic Disease · doi:10.1177/2040622311401775 · Cited by 32 · see citing works
“There are no clear data on the effect on cardiovascular outcomes of fluid management as a means of blood pressure control despite clear evidence that volume adjustment is effective at reducing blood pressure for people on haemodialysis [Agarwal et al. 2009].”
BackgroundPre-admission proteinuria impacts risk of non-recovery after dialysis-requiring acute kidney injury
Lee, B. J., Go, A., Parikh, R., Leong, T., Tan, T., Walia, S., Hsu, R. K., Liu, K. D., & Hsu, C.-Y. (2018) · Kidney International · doi:10.1016/j.kint.2017.10.017 · Cited by 28 · see citing works
Why Assistive Technology Is Needed for Probing of Dry Weight
Sinha, A. D. (2011) · Blood Purification · doi:10.1159/000321840 · Cited by 28
Blood pressure management in hemodialysis: what have we learned?
Peixoto, A., & Santos, S. (2010) · Current opinion in nephrology and hypertension · doi:10.1097/mnh.0b013e32833f0d82 · Cited by 28 · see citing works
Disordered aldosterone-volume relationship in end-stage kidney disease
Bomback, A. S., Kshirsagar, A., Ferris, M., & Klemmer, P. (2009) · Journal of the Renin-Angiotensin-Aldosterone System · doi:10.1177/1470320309352353 · Cited by 28 · see citing works
“Yet the discussion has heretofore centred primarily on blood pressure.(28,29) In our opinion, this has led to an unfortunate neglect of the inflammatory role of aldosterone in these high volume states.”
BackgroundBrain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients
Stenberg, J., Melin, J., Lindberg, M., & Furuland, H. (2019) · Hemodialysis international. International Symposium on Home Hemodialysis · doi:10.1111/hdi.12751 · Cited by 27
Ott, C., Schmid, A., Ditting, T., Veelken, R., Uder, M., & Schmieder, R. (2019) · Clinical and Experimental Nephrology · doi:10.1007/s10157-019-01697-7 · Cited by 27 · see citing works
Chazot, C., Vo-Van, C., Deléaval, P., Lorriaux, C., Hurot, J., Mayor, B., & Jean, G. (2012) · Blood Purification · doi:10.1159/000337101 · Cited by 27
- Authors
- Agarwal, R., Alborzi, P., Satyan, S., & Light, R. P.
- Affiliations
- Richard L. Roudebush VA Medical Center (US)
- Venue
- Hypertension
- Published
- 2009-03
- Volume
- 53
- Issue
- 3
- Pages
- 500-507
- ISSN
- 0194-911X (ISSN-L)
- 1524-4563
- PMC
- PMC2679163
- OpenAlex
- W2115611820
- Cited by
- 349
- References
- 35
- Citations by year
- 2026: 7 · 2025: 15 · 2024: 12 · 2023: 17 · 2022: 19 · 2021: 22 · 2020: 21 · 2019: 19 · 2018: 20 · 2017: 22 · 2016: 22 · 2015: 26 · 2014: 20 · 2013: 16 · 2012: 32
- FWCI
- 20.97
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Hypertension (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- IUScholarWorks (Indiana University) (submittedVersion)
- Funders
- Dialysis Clinics
- U.S. Public Health Service (5R01-NIDDK062030-05)
- National Institute of Diabetes and Digestive and Kidney Diseases (R01DK062030)
- Topics
- Health Sciences › Medicine › Nephrology › Dialysis and Renal Disease Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Nephrology › Parathyroid Disorders and Treatments
- Keywords
- dry weight reduction, ultrafiltration, blood pressure control, hypotension, quality of life, dialysis
- MeSH terms
- Adult, Aged, Blood Pressure, Diastole, Female, Renal Dialysis, Humans, Hypertension, Kidney Failure, Chronic, Male, Middle Aged, Prospective Studies, Quality of Life, Systole, Time Factors, Weight Loss, Hemodiafiltration
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