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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 [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]
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In the citing paper
“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]
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Special situations: Intradialytic hypertension/chronic hypertension and intradialytic hypotension
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“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. N. V., & Inrig, J. K. (2011) · Pediatric Nephrology · doi:10.1007/s00467-011-1775-3 · Cited by 43
“Gradual dry weight reduction leads to improved ambulatory BP in hypertensive HD patients [24].”
BackgroundMethodAgarwal, R. (2010) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfq171 · Cited by 42
“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. F. F., Peixoto, A. J., & Perazella, M. A. (2012) · Advances in Chronic Kidney Disease · doi:10.1053/j.ackd.2012.03.003 · Cited by 37
“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 & Hypertension · doi:10.1097/mnh.0b013e3283319b9d · Cited by 44
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. S., Kim, S., Yoo, T., & Kim, J.-K. (2023) · Clinical Hypertension · doi:10.1186/s40885-023-00240-x · Cited by 52
“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. H., Park, J., Kim, H., Kee, Y. K., Park, J. T., Han, S. H., Yang, C. W., Kim, N., Kim, Y. S., Kang, S., et al. (2018) · Scientific Reports · doi:10.1038/s41598-018-32281-w · Cited by 42
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 Transplantation · doi:10.1093/ndt/gfs384 · Cited by 35
“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
Georgianos, P. I., Pikilidou, M. I., Liakopoulos, V., Balaskas, E. V., & Zebekakis, P. E. (2018) · Hypertension Research · doi:10.1038/s41440-018-0025-5 · Cited by 32
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
“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. R., Seuß, H., Hammon, R., Rosenhauer, D., Janka, R., Cavallaro, A., Luft, F. C., Titze, J. M., et al. (2017) · Academic Radiology · doi:10.1016/j.acra.2017.03.012 · Cited by 35
Penne, E., Levin, N., & Kotanko, P. (2010) · Blood Purification · doi:10.1159/000317124 · Cited by 32
“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
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 33
“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
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. J., & Santos, S. F. F. (2010) · Current Opinion in Nephrology & Hypertension · doi:10.1097/mnh.0b013e32833f0d82 · Cited by 22
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
“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. A., Uder, M., & Schmieder, R. E. (2019) · Clinical and Experimental Nephrology · doi:10.1007/s10157-019-01697-7 · Cited by 30
Chazot, C., Vo‐Van, C., Deléaval, P., Lorriaux, C., Hurot, J. M., Mayor, B., & Jean, G. (2012) · Blood Purification · doi:10.1159/000337101 · Cited by 28
Metadata
- 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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