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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]
Experimental — accuracy not yet measuredThe check wasn’t confident either way, so it gives no verdict — never disputed.
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]
Experimental — accuracy not yet measured
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“These factors include immunosuppressant therapy like calcineurin inhibitors and glucocorticoids, altered sodium regulation and the activation of the renin–angiotensin–aldosterone system (RAAS)([11]), obesity and post-KTx weight gain([12]), transplant renal artery stenosis([13]), volume overload, and allograft insuffic…”
BackgroundHypertension in Patients Receiving Dialysis: A Review of the Current Clinical Approach
Rowan, C., Mahony, S., & Redahan, L. (2023) · EMJ Nephrology · doi:10.33590/emjnephrol/10105805 · Cited by 2
Earasi, K., Mihaltses, J., Kennedy, J., Rao, S., Holsten, L., Mazimba, S., Doyle, A., & Mihalek, A. (2022) · Clinical Transplantation · doi:10.1111/ctr.14799 · Cited by 1
Online hemofiltration in incremental dialysis prescription
Correia, S., Silva, F., Tavares, J., Cabrita, A., & Queirós, J. (2021) · doi:10.32932/pjnh.2021.01.098 · Cited by 1
Haemodialysis, blood pressure and risk: at the limit of non-randomized evidence.
Ng, S. Y. A., Haynes, R., & Herrington, W. (2020) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gfaa043 · Cited by 1
Bobot, M., Zieleskiewicz, L., Jourde-Chiche, N., Kotze, C. V., Ebersolt, M., Dussol, B., Sallée, M., Chopinet, S., Berland, Y., Brunet, P., et al. (2019) · doi:10.21203/rs.2.17834/v1 · Cited by 1
Redefining the Burden of Intradialytic Hypotension in the Modern Era of Hemodialysis
Buren, P. V. V. (2019) · American Journal of Nephrology · doi:10.1159/000500878 · Cited by 1
Patient-Centered Approach for Hypertension Management in End-Stage Kidney Disease: Art or Science?
Gosmanova, E. O., & Kovesdy, C. P. (2018) · Seminars in Nephrology · doi:10.1016/j.semnephrol.2018.05.006 · Cited by 2
Does pharmacotherapy improve cardiovascular outcomes in hemodialysis patients?
Mittal, M., Aggarwal, K. B., Littrell, R. L., Agrawal, H., & Alpert, M. (2015) · Hemodialysis International · doi:10.1111/hdi.12352 · Cited by 1
Dealing with hypertension in hemodialysis patients
Cavalli, A., & Pontoriero, G. (2015) · Giornale di Techniche Nefrologiche e Dialitiche · doi:10.5301/gtnd.2015.14428
Hypertension: Fluid overload and post-dialysis hypertension
Mallamaci, F., & Tripepi, G. (2014) · Nature Reviews Nephrology · doi:10.1038/nrneph.2014.175 · Cited by 1
The hypo/hypertension quandary.
Henderson, L. (2011) · Artificial Organs · doi:10.1111/j.1525-1594.2011.01277.x · Cited by 1
Hypertension and Chronic Kidney Disease
Sternlicht, H., & Bakris, G. L. (2017) · Elsevier eBooks · doi:10.1016/b978-0-323-42973-3.00033-0 · Cited by 1
Czerpak, K. R. F., Vergara, E. G., Barril, G., Pérez‐Fernández, E., Benavides, N., de la Flor, J. C., Méndez, Á., & Martín, R. (2020) · Nefrología · doi:10.1016/j.nefro.2020.06.005 · Cited by 2
Lu, H., Cheng, S.-S., Liu, X.-Z., Jin, M.-L., Sun, F., & Sun, Q.-M. (2026) · Journal of Clinical Medicine · doi:10.3390/jcm15187021
“In our study, the IDH group had lower pre-HD and post-HD blood pressure, as excess volume is an important factor causing hypertension in patients on HD [15,16].”
Mußnig, S., Naar, L., Theodorakopoulou, M. P., Niknam, J., Beige, J., Keane, D. F., Schneditz, D., Sarafidis, P. A., Wassertheurer, S., Mayer, C. C., et al. (2026) · Clinical Kidney Journal · doi:10.1093/ckj/sfag273
“Inter-ventional trials, such as the “Dry-weight reduction in hypertensive hemodialysis patients (DRIP)”trial [ 16 ] or the “Lung Water by Ultrasound-Guided Treatment in Hemodialysis Patients (LUST)” ambulatory blood pressure measurement (ABPM) study demonstrated that lowering or fine-tuning dry…”
Díaz, A., Delgado, B., Argaiz, E., Vega, O., Correa-Rotter, R., & Rodríguez-Iturbe, B. (2026) · Physiological Reports · doi:10.14814/phy2.70903
“Copeptin (pmol/L) 26.7 ± 12.9 (20.9–32.4) 12.4 ± 3.6 (10.3–14.4) from 4 to 8 weeks of downward probing the dry weight with ultrafiltration has been conclusively demonstrated (Agarwal et al., 2009).”
InfluentialTen tips to control blood pressure in haemodialysis patients
Chinnappa, S., Craenenbroeck, A. V. V., Dounousi, E., Fernandez-Fernandez, B., Iatridi, F., Piko, N., Stegbauer, J., Torino, C., Vogt, L., Valdivielso, J. M., et al. (2026) · Clinical Kidney Journal · doi:10.1093/ckj/sfag128
“In kidney failure, impaired sodium and water excretion lead to chronic extracellular fluid expansion, increasing venous return, cardiac preload, and stroke volume, thereby elevating BP [ 16 , 17 ].”
What Is the Optimal Timing for Intradialytic Resistance Exercise? A Randomized Controlled Trial.
Bingölbali, Ö., & Oğuz, S. (2026) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2026.03.013
Georgianos, P., Kamperidis, V., Kourtidou, C., Roumeliotis, A., Leivaditis, K., & Liakopoulos, V. (2026) · Life · doi:10.3390/life16030380
“Over a follow-up period of 8 weeks, as compared with no intervention in the control group, probing of dry-weight in the ultrafiltration group provoked a reduction of − 6.6/ − 3.3 mmHg in 44-h interdialytic ambulatory blood pressure (BP) [5].”
InfluentialKanjanasuphak, N. (2026) · Journal of the Nephrology Society of Thailand · doi:10.63555/jnst.2026.283000
Salem, M. S., Hamdy, N. A., Elghoneimy, H., & El-Gowelli, H. M. (2026) · BMC Nephrology · doi:10.1186/s12882-025-04726-8
“Interventions for resistant hypertension among patients on dialysis focus, first, on targeting dry weight adjustment to achieve euvolemia and, secondly, on anti-hypertensive agents [5, 10, 11].”
Bioimpedance spectroscopy to estimate target weight in patients on maintenance haemodialysis
Stigger, K., Kohn, E. R., Nobre, R. K., Pitol, G., Feter, N., & Böhlke, M. (2025) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd016044
Sandys, V. K., Bhat, L., O’Hare, E., Hudson, A., O’Seaghdha, C. M., & Sexton, D. J. (2025) · Nephrology · doi:10.1111/nep.70112
Feasibility and safety of RDN in patients with ESRD and RHT
He, L., Han, C., Yuxing, L., Zhou, W., Jinzi, S., & Zhoufei, F. (2025) · medRxiv · doi:10.1101/2025.08.04.25332993
“These methods have been shown to lower blood pressure in some ESRD patients [19-20].”
Hypertension in Hemodialysis Patients
Abramovitz, B., & Nemecek, B. D. (2025) · Nephrology Self-Assessment Program · doi:10.58483/nsap.00562024
Home versus routine dialysis-unit blood pressure recordings among patients on hemodialysis
Leonidou, K., Georgianos, P. I., Κόλλιας, Α., Kontogiorgos, I., Vaios, V., Leivaditis, K., Karligkiotis, A., Stamellou, E., Balaskas, E. V., Stergiou, G. S., et al. (2025) · Journal of Human Hypertension · doi:10.1038/s41371-025-01007-7 · Cited by 1
Intradialysis hypertension, a diagnosis to be discovered.
Sanz, J., Jaldo, M. T., Procaccini, F., Chacón, E., & Albalate, M. (2024) · Nefrología · doi:10.1016/j.nefroe.2024.10.003
Ohashi, N., Sakao, Y., Uchiyama, Y., Aoki, T., Ishigaki, S., Iwakura, T., Isobe, S., Fujikura, T., Kato, A., & Yasuda, H. (2024) · Clinical and Experimental Nephrology · doi:10.1007/s10157-024-02541-3
“Blood pressure can be normalized in 60% of patients by correcting this abnormality [2, 3].”
Hypertonietherapie bei Nierenerkrankungen
Boger, L., & Saritas, T. (2024) · Nephrologie aktuell · doi:10.1055/a-2215-3675
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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