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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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BackgroundSelf-citationSalt-tolerance screening in Limonium sinuatum varieties with different flower colors
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BackgroundInfluentialManagement of acute intradialytic cardiovascular complications: Updated overview (Review)
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“Several observational studies (2,3) and one randomized controlled trial (4) support the notion that among hypertensive hemodialysis patients augmented volume removal effectively lowers BP.”
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“Volume reduction to improve BP control has recently been given further attention (81) with patients in the DRIP trial randomized to probing of dry weight or conventional care.”
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“(12) suggests that there is great benefit on BP and overall heart performance if patients have dry weight reduced by as little as 1 kg.”
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“Several observational studies showed that strict postHD weight control was associated with better short term outcome [10] or long term survival [11], but other studies associated strict fluid control with increased morbidity and / or hospitalization [12,13].”
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Roberts, M. A., Pilmore, H., Tonkin, A. M., Garg, A. X., Pascoe, E. M., Badve, S. V., Cass, A., Ierino, F. L., & Hawley, C. M. (2012) · American Journal of Kidney Diseases · doi:10.1053/j.ajkd.2012.04.026 · Cited by 14
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Uraemic toxins versus volume and water as the major factor that matters with dialysis.
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“[42] found that flatter relative plasma volume slopes to detect hypervolaemia were associated with all-cause mortality.”
BackgroundPrevalence of fluid overload in an urban US hemodialysis population: A cross‐sectional study
Moissl, U., Fuentes, L., Hakim, M. I., Hassler, M., Kothari, D. A., Rosales, L., Zhu, F., Raimann, J., Thijssen, S., & Kotanko, P. (2021) · Hemodialysis international. International Symposium on Home Hemodialysis · doi:10.1111/hdi.12986 · Cited by 11
Prevalence and control of hypertension among patients on haemodialysis
Tsikliras, N., Georgianos, P. I., Vaios, V., Minasidis, E., Anagnostara, A., Chatzidimitriou, C., Syrganis, C., Liakopoulos, V., Zebekakis, P. E., & Balaskas, E. V. (2020) · European Journal of Clinical Investigation · doi:10.1111/eci.13292 · Cited by 9
Reliability of Blood Pressure Parameters for Dry Weight Estimation in Hemodialysis Patients
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“In a previous study, there was a direct relationship between decreased body weight and reduced BP during follow-up (8).”
BackgroundPrimary and Secondary Hypertension
Blumenfeld, J. D., Liu, F., & Laragh, J. H. (2012) · Elsevier eBooks · doi:10.1016/b978-1-4160-6193-9.10046-6 · Cited by 11
Association of Bioimpedance Parameters with Increases in Blood Pressure during Hemodialysis
Elsayed, E., Farag, Y. M. K., Ravi, K. S., Chertow, G. M., & McCausland, F. R. (2023) · American Society of Nephrology. Clinical Journal · doi:10.2215/cjn.0000000000000356 · Cited by 10
Jung, J.-Y., Yoo, K. D., Kang, E., Kang, H., Kim, S. H., Kim, H., Kim, H., Park, T.-J., Suh, S.-H.-O., Jeong, J., et al. (2022) · The Korean Journal of Internal Medicine · doi:10.3904/kjim.2021.543 · Cited by 10
“A multi-faceted approach is needed, because several factors can affect blood pressure treatment as confounders; these include interdialytic blood pressure variability [118], intradialytic anti-hypertensive drug removal through dialysis membranes [119], body fluid changes [120], reduced vascular elasticity, and post-di…”
BackgroundFive Things to Know About Intradialytic Hypertension
Prasad, B., Hemmett, J., & Suri, R. S. (2022) · Canadian Journal of Kidney Health and Disease · doi:10.1177/20543581221106657 · Cited by 10
Shaman, A. M., Smyth, B. J., Arnott, C. G., Palmer, S. C., Mihailidou, A. S., Jardine, M., Gallagher, M., Perkovic, V., & Jun, M. (2020) · Clinical Journal of the American Society of Nephrology · doi:10.2215/cjn.12201019 · Cited by 13
The Dialysis Sodium Gradient: A Modifiable Risk Factor for Fluid Overload
Trinh, E., & Weber, C. L. (2017) · Nephron Extra · doi:10.1159/000453674 · Cited by 10
Assessing blood pressure control in dialysis patients: finally a step forward.
Hopkins, K. A., & Bakris, G. (2009) · HYPERTENSION · doi:10.1161/hypertensionaha.108.126300 · Cited by 10
Coronary Artery Disease: Therapeutics and Drug Discovery
Wang, M., Crusio, W. E., & Lambris, J. D. (2020) · Advances in Experimental Medicine and Biology · doi:10.1007/978-981-15-2517-9 · Cited by 10
Mazza, A., Dell’Avvocata, F., Torin, G., Bulighin, F., Battaglia, Y., & Fiorini, F. (2023) · Current Hypertension Reports · doi:10.1007/s11906-023-01264-2 · Cited by 14
“Furthermore, a significant body of literature indicates that the correction of volume overload by removing excess sodium and reducing target dry weight can improve (BP) levels in approximately 60% of extracorporeal dialysis patients [22–24].”
BackgroundCardiovascular Disease Assessment Prior to Kidney Transplantation
Ewing, E. C., & Edwards, A. R. (2022) · Methodist DeBakey Cardiovascular Journal · doi:10.14797/mdcvj.1117 · Cited by 7
Intra‐dialytic hypotension: Identifying patients most at risk
Sangala, N., Gangaram, V., Atkins, K., Elliot, G. R., & Lewis, R. (2017) · Journal of renal care · doi:10.1111/jorc.12203 · Cited by 9
“…reduces both intra-dialytic symptomatology and delta systolic (Machek et al. 2010) whilst a reduction in hydration status is associated with increased symptoms, increased risk of IDH and an increase in delta systolic (Wabel et al. 2008; Agarwal et al. 2009; Chazot et al. 2012; Hur et al. 2013).”
BackgroundPrevalence and Risk Factors of Hypertension in Hemodialysis
Gorsane, I., Mahfoudhi, M., Younsi, F., Helal, I., & Abdallah, T. B. (2015) · Open Journal of Nephrology · doi:10.4236/ojneph.2015.52009 · Cited by 10
Hypertension Treatment for Patients with Advanced Chronic Kidney Disease
Sinha, A. D., & Agarwal, R. (2014) · Current Cardiovascular Risk Reports · doi:10.1007/s12170-014-0400-y · Cited by 4
Self-citationAgarwal, R. (2012) · Journal of the American Society of Hypertension · doi:10.1016/j.jash.2012.08.009 · Cited by 4
“1 mm diastolic in the same period.(22) This was not associated with deterioration in quality of life but may have been associated with a slight increase in adverse events that were not statistically significant.”
BackgroundSelf-citationCardiovascular determinants of prognosis in normotensive hemodialysis patients
Yu, W.-C., Lin, Y.-P., Chuang, S., Lin, I., & Chenb, C.-H. (2012) · BMC Nephrology · doi:10.1186/1471-2369-13-115 · Cited by 9
Should All Hypertensive Dialysis Patients Receive a Blocker of the Renin-Angiotensin System?
Sinha, A. D., & Agarwal, R. (2010) · Current Hypertension Reports · doi:10.1007/s11906-010-0137-z · Cited by 9
“We believe that the essential first step in treating any dialysispatient isassiduous attention tovolumestatusthrough dietary salt restriction, ultrafiltration, and low-sodium dialysate [ 5 ].”
BackgroundSelf-citationIntradialytic Hypertension in Maintenance Hemodialysis
Iatridi, F., Theodorakopoulou, M. P., Karagiannidis, A. G., & Sarafidis, P. (2024) · Current Hypertension Reports · doi:10.1007/s11906-024-01320-5 · Cited by 8
“Previous randomized studies performed in the general hemodialysis population have shown that dry weight probing, either using clinical criteria [60] or objective methods such as lung ultrasound to assess volume status [61], can lead to significant reductions in 48-h ambulatory SBP.”
Ai, S., Xu, Q.-Y., Chen, G., Zheng, K., Qin, Y., & Li, X.-M. (2024) · Frontiers in Medicine · doi:10.3389/fmed.2024.1449919 · Cited by 8
“Previous studies have demonstrated enhanced volume removal during dialysis improved blood pressure control in patients on maintenance hemodialysis (19).”
BackgroundEpidemiology, Pathophysiology, and Clinical Perspectives of Intradialytic Hypertension
Theofilis, P., Vordoni, A., & Kalaitzidis, R. (2023) · American Journal of Nephrology · doi:10.1159/000531047 · Cited by 8
Clark, E. G., James, M., Hiremath, S., Sood, M., Wald, R., Garg, A., Silver, S., Tan, Z., & van Walraven, C. (2023) · American Society of Nephrology. Clinical Journal · doi:10.2215/cjn.0000000000000173 · Cited by 8
Uncertainties in BP management in dialysis patients
Doulton, T. W. R., Swift, P. A., Murtaza, A., & Dasgupta, I. (2020) · Seminars in Dialysis · doi:10.1111/sdi.12880 · Cited by 12
Blood pressure targets and pharmacotherapy for hypertensive patients on hemodialysis
Maruyama, T., Takashima, H., & Abe, M. (2020) · Expert Opinion on Pharmacotherapy · doi:10.1080/14656566.2020.1746272 · Cited by 11
Turning the Tide: Improving Fluid Management in Dialysis through Technology.
Flythe, J. (2017) · Journal of the American Society of Nephrology · doi:10.1681/asn.2017050491 · Cited by 8
Evaluation and Treatment of Hypertension in End-Stage Renal Disease Patients on Hemodialysis
Buren, P. N. V. (2016) · Current Cardiology Reports · doi:10.1007/s11886-016-0805-y · Cited by 14
Pharmacologic Treatment of Hypertension in Patients With Chronic Kidney Disease
Talreja, H., Ruzicka, M., & McCormick, B. B. (2013) · American Journal of Cardiovascular Drugs · doi:10.1007/s40256-013-0009-4 · Cited by 10
Mercadal, L., Piékarski, C., Renaux, J., Petitclerc, T., & Deray, G. (2012) · JN. Journal of Nephrology (Milano. 1992) · doi:10.5301/jn.5000084 · Cited by 8
Interdialytic Hypertension—An Update
Agarwal, R. (2011) · Advances in Chronic Kidney Disease · doi:10.1053/j.ackd.2010.10.001 · Cited by 9
“In the recently reported dry-weight reduction in hypertensive hemodialysis patients trial, long-term hypertensive hemodialysis patients were randomly assigned to ultrafiltration or control groups.(50) The additional ultrafiltration group (n 1⁄4 100) had the dry weight probed without increasing the time or the duration…”
BackgroundSelf-citationHui, R. (2020) · Advances in experimental medicine and biology · doi:10.1007/978-981-15-2517-9_6 · Cited by 13
Doulton, T., Adam, M., Durman, K., Fan, S. L., Forbes, A., Jenkinson, E., Mallindine, C., McCafferty, K., Sinha, M. D., Stewart, D., et al. (2025) · BMC Nephrology · doi:10.1186/s12882-025-04451-2 · Cited by 8
“Several observational studies and small trials demonstrate improvement in BP control in both people on peritoneal and haemodialysis [109, 113, 116, 119, 122, 123, 130, 132].”
Lung Ultrasound Guided Management of Pulmonary Congestion in Hemodialysis
Kaysi, S., Hamad, A., Boulgheraif, A., Bonkain, F., Libertalis, M., Ayyach, A. A., Baz, M., Farah, I., Ibrahim, R., Ateya, H., et al. (2025) · Kidney360 · doi:10.34067/kid.0000000873 · Cited by 7
“31 BPHM may bridge the gap between these two methods by providing better data than intradialytic BP readings; however, it remains less valuable than the interdialytic ambulatory BP measurement.”
Hornig, C., Canaud, B., & Bowry, S. (2023) · Blood Purification · doi:10.1159/000530816 · Cited by 7
Management of intradialytic hypertension: current evidence and future perspectives
Iatridi, F., Theodorakopoulou, M. P., Papagianni, A., & Sarafidis, P. (2022) · Journal of Hypertension · doi:10.1097/hjh.0000000000003247 · Cited by 7
“In the Dry-weight Reduction in Hypertensive hemodialysis Patients (DRIP) trial, dry-weight probing through intensified ultrafiltration not only lowered interdialytic BP but also beneficially affected the intradialytic BP slope [26].”
BackgroundMethodGermain, M., Greco, B., Hodgins, S., Chapagain, B., Thadhani, R., Wojciechowski, D., Crisalli, K., Nathanson, B., & Chait, Y. (2021) · JN. Journal of Nephrology (Milano. 1992) · doi:10.1007/s40620-021-01029-7 · Cited by 7
Volume management in haemodialysis patients
See, E. J., & Polkinghorne, K. (2020) · Current opinion in nephrology and hypertension · doi:10.1097/mnh.0000000000000642 · Cited by 7
“In the DRIP trial, dry weight reduction in clinically euvolemic haemodialysis patients with hypertension lead to a significant reduction in ambulatory BP measurement [23].”
Background
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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