Home Blood Pressures Are of Greater Prognostic Value than Hemodialysis Unit Recordings
Abstract
BACKGROUND AND OBJECTIVES: Although ambulatory BP recordings are found to be superior to dialysis unit recordings in predicting outcomes, ambulatory BP are difficult to obtain in the day-to-day treatment of hemodialysis patients. Home BP agree well with ambulatory BP, but the prognostic significance of home BP recordings is unknown in hemodialysis patients. This study ascertained the role of home BP in predicting all-cause and cardiovascular mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A prospective cohort study was conducted in 150 patients who were on chronic hemodialysis dialyzing at four university-affiliated units. BP was self-measured at home for 1 wk, for an interdialytic interval by ambulatory recording, and by "routine" and standardized methods in the dialysis unit for 2 wk. Patients were followed for a median of 24 mo to assess the end points of all-cause and cardiovascular mortality. RESULTS: Cardiovascular death occurred in 26 (17%) patients and death in 46 (31%) patients. A 1-SD increase in systolic BP increased the risk for death by 1.35 (95% CI 0.99 to 1.84) and in diastolic BP by 1.40 (95% CI 1.03 to 1.93) for home BP and between 0.97 to 1.19 (P > 0.20) for all-cause mortality for dialysis unit BP recording. A dose-response relationship between increasing quartiles of home BP and all-cause mortality and cardiovascular mortality was seen. CONCLUSIONS: Self-measured systolic BP of 125 to 145 mmHg and of 115 to 125 mmHg by ambulatory BP is associated with the best prognosis in hemodialysis patients.
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Patients with CKD on haemodialysis are profoundly different from patients with CKD not on dialysis because of varying states of volume excess and volume accumulation in the interdialytic period.
“Patients with CKD on haemodialysis are profoundly different from patients with CKD who are not on dialysis; this is so because of varying states of volume excess among patients and volume accumulation in the interdialytic period [204–206].”
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2009)
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“Discussion The main findings of the present study are: (1) home BP increases over time after hemodialysis treatment; (2) this relationship is non-linear and plateaus after approximately 2 days; (3) probing dry-weight does not perturb the time-dependent relationship of home BP but steepens the slope for ambulatory BP;…”
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“There are other wrinkles to consider when comparing home BP with ABPM.”
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“A subsequent study involving the same population found ABPM and home BP monitoring to be more predictive than in-center readings for mortality (14).”
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“In addition, home BPs correlate better with CV outcomes and thus have more robust prognostic value (10).”
BackgroundDESIGN OF THE BLOOD PRESSURE IN DIALYSIS (BID) PILOT STUDY
Gul, A., Harford, A., Horowitz, B., Bedrick, E., Miskulin, D., Gassman, J., Chen, J. L. T., Paine, S., Kusek, J., Unruh, M., et al. (2014) · American Journal of the Medical Sciences · doi:10.1097/maj.0b013e31827daee5 · Cited by 26
“Conversely, Agarwal et al(12) reported that RDUSBPM and SDUSBPM were significantly weaker than HBPM and ABPM as predictors of LVH and all-cause mortality.(13) ABPM monitoring can be cumbersome, disturb sleep patterns and be associated with reduced physical activity and poor adherence.”
Dunlop, J. L., Vandal, A., de Zoysa, J., Gabriel, R., Haloob, I., Hood, C. J., Matheson, P. J., Mcgregor, D. O., Rabindranath, K., Semple, D., et al. (2013) · BMC Nephrology · doi:10.1186/1471-2369-14-149 · Cited by 26 · see citing works
“Readings will be made 3 times per day (on waking up, between noon and 1900, and before bed) during the 7days immediately prior to 3, 6, 9 and 12 months [150,157,158].”
MethodHome Blood Pressure Monitoring: How Good a Predictor of Long-Term Risk?
Sheikh, S., Sinha, A. D., & Agarwal, R. (2011) · Current Hypertension Reports · doi:10.1007/s11906-011-0193-z · Cited by 26 · see citing works
“Additionally, when the BP values were divided into quartiles, increasing quartiles of clinic BP by any method had no significant relationship to all-cause mortality, whereas increasing quartiles of home BP had a significant linear trend associated with increasing mortality (P=0.05) [ 38 ].”
BackgroundMethodInfluentialSelf-citationBlood Pressure Target for the Dialysis Patient
McCallum, W., & Sarnak, M. (2018) · Seminars in dialysis · doi:10.1111/sdi.12754 · Cited by 24 · see citing works
“94) in risk for mortality for each standard deviation (SD) higher systolic BP obtained by ABPM.(20) There was a similar pattern using home BP measurements (HR = 1.”
MethodInfluentialZhou, Y.-L., Liu, J., Ma, L.-J., Sun, F., Shen, Y., Huang, J., & Cui, T.-G. (2013) · Blood Purification · doi:10.1159/000346631 · Cited by 24 · see citing works
Stern, A., Sachdeva, S., Kapoor, R., Singh, J., & Sachdeva, S. (2014) · Journal of clinical and diagnostic research : JCDR · doi:10.7860/jcdr/2014/8253.4471 · Cited by 23 · see citing works
“But by far the best way to monitor the blood pressure in these patients would be at home by the patient by an automatic ambulatory blood pressure monitoring [16,17].”
BackgroundSystolic Blood Pressure and Mortality in Patients on Hemodialysis
Chang, T. (2011) · Current Hypertension Reports · doi:10.1007/s11906-011-0223-x · Cited by 23 · see citing works
“In a single-center study of 150 patients on hemodialysis, SBP was measured at home several times daily for 1 week and averaged; these patients also had 44-hour interdialytic ambulatory BP monitoring [ 24 ].”
MethodBansal, N., Glidden, D., Mehrotra, R., Townsend, R., Cohen, J., Linke, L., Palad, F., Larson, H., & Hsu, C.-Y. (2020) · American Journal of Kidney Diseases · doi:10.1053/j.ajkd.2020.06.014 · Cited by 22 · see citing works
Vascular calcification: When should we interfere in chronic kidney disease patients and how?
Din, U. E. E., Salem, M., & Abdulazim, D. (2016) · World Journal of Nephrology · doi:10.5527/wjn.v5.i5.398 · Cited by 22 · see citing works
Hompesch, C., Ma, T.-W., Neyra, J. A., Ripley, L., Xiao, G., Inrig, J., Toto, R., & Buren, P. V. V. (2016) · Kidney & Blood Pressure Research · doi:10.1159/000443427 · Cited by 22
“Compared to individual BP measurements obtained in the hemodialysis unit, the average of BP measurements obtained during the interdialytic period provides better prognostic information for adverse clinical outcomes, including mortality [1].”
Monitoring of hemodialysis quality-of-care indicators: why is it important?
Grangé, S., Hanoy, M., Roy, F. L., Guerrot, D., & Godin, M. (2013) · BMC Nephrology · doi:10.1186/1471-2369-14-109 · Cited by 22
“In a prospective cohort study conducted in 150 chronic hemodialysis patients, self-measured and ambulatory systolic BP between 125 and 145 mmHg, and between 115 and 125 mmHg, respectively, were associated with a decreased risk of death [23].”
BackgroundInterdialytic Ambulatory Blood Pressure in Patients with Intradialytic Hypertension
Buren, P. V. V., Toto, R., & Inrig, J. (2012) · Current opinion in nephrology and hypertension · doi:10.1097/mnh.0b013e32834db3e4 · Cited by 22 · see citing works
“It is known that home and ambulatory BP measurements from the interdialytic period are better predictors of mortality than individual prehemodialysis or posthemodialysis BP measurements [6].”
BackgroundPractical Use of Home Blood Pressure Monitoring in Chronic Kidney Disease
Sanghavi, S. F., & Vassalotti, J. (2014) · CardioRenal Medicine · doi:10.1159/000363114 · Cited by 21 · see citing works
Renal Association Clinical Practice Guideline on Cardiovascular Disease in CKD
Holt, S. G., & Goldsmith, D. J. A. (2011) · Nephron Clinical Practice · doi:10.1159/000328065 · Cited by 18 · see citing works
Blood Pressure Control in Conventional Hemodialysis.
Georgianos, P., & Agarwal, R. (2018) · Seminars in dialysis · doi:10.1111/sdi.12741 · Cited by 20 · see citing works
Self-citationRecent advances in the management of hemodialysis patients: a focus on cardiovascular disease
Jablonski, K., & Chonchol, M. (2014) · F1000Prime Reports · doi:10.12703/p6-72 · Cited by 17 · see citing works
“To add a further complication, home blood pressure measurements may associate more closely with CVD than clinic blood pressure [37].”
BackgroundHypertension in end-stage renal disease: different measures and their prognostic significance.
Hörl, W. (2010) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gfq428 · Cited by 20 · see citing works
“Routine peri-dialytic BP recordings performed by a dialysis unit staff shortly before and after the HD session are highly variable and poorly reproducible [4,5] and do not correlate well with end-organ damage [6,7].”
BackgroundKorean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment
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. (2021) · Kidney Research and Clinical Practice · doi:10.23876/j.krcp.21.600 · Cited by 19 · see citing works
The controversies of diagnosing and treating hypertension among hemodialysis patients
Agarwal, R. (2012) · Seminars in dialysis · doi:10.1111/j.1525-139x.2012.01092.x · Cited by 19 · see citing works
“reported that ambulatory BP was of greater prognostic value compared with dialysis unit BP recordings (13).”
ResultSelf-citationMedian Intradialytic Blood Pressure Can Track Changes Evoked by Probing Dry-Weight
Agarwal, R., & Light, R. P. (2010) · Clinical Journal of the American Society of Nephrology · doi:10.2215/cjn.08341109 · Cited by 19 · see citing works
“We used ambulatory BP as a reference standard because ambulatory BP recording is an accurate estimate of the arterial pressure and shares a stronger relationship with all-cause mortality compared with BPs obtained in the dialysis unit (25).”
MethodSelf-citationHypertension in patients with chronic kidney disease
Chanda, R., & Fenves, A. (2009) · Current Hypertension Reports · doi:10.1007/s11906-009-0056-z · Cited by 19 · see citing works
Big data in nephrology—a time to rethink
Agarwal, R., & Sinha, A. D. (2018) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gfx330 · Cited by 19
Self-citationLi, H., Xue, J., Dai, W., Liao, X., Zhu, P.-Y., Zhou, Q.-L., & Chen, W.-H. (2020) · Kidney & Blood Pressure Research · doi:10.1159/000508979 · Cited by 18 · see citing works
Agarwal, R. (2016) · HYPERTENSION · doi:10.1161/hypertensionaha.115.07052 · Cited by 18 · see citing works
Self-citationEkart, R., Kanič, V., Pečovnik-Balon, B., Bevc, S., & Hojs, R. (2012) · Kidney & Blood Pressure Research · doi:10.1159/000336357 · Cited by 18 · see citing works
Chazot, C. (2009) · JN. Journal of Nephrology (Milano. 1992) · doi:10.1093/joneph/22.5.587 · Cited by 17 · see citing works
Kollias, A., Kyriakoulis, K., Komnianou, A., Stathopoulou, P., & Stergiou, G. (2024) · Journal of Hypertension · doi:10.1097/hjh.0000000000003653 · Cited by 16 · see citing works
- Authors
- Alborzi, P., Patel, N., & Agarwal, R.
- Affiliations
- Richard L. Roudebush VA Medical Center (US)
- Corresponding author
- Agarwal, Rajiv
- ORCID
- Agarwal, Rajiv
- Venue
- Clinical Journal of the American Society of Nephrology
- Published
- 2007-11
- Volume
- 2
- Issue
- 6
- Pages
- 1228-1234
- ISSN
- 1555-9041 (ISSN-L)
- OpenAlex
- W2128457806
- Cited by
- 248
- References
- 0
- Citations by year
- 2026: 3 · 2025: 12 · 2024: 12 · 2023: 15 · 2022: 10 · 2021: 14 · 2020: 16 · 2019: 16 · 2018: 15 · 2017: 16 · 2016: 24 · 2015: 14 · 2014: 11 · 2013: 9 · 2012: 18
- FWCI
- 6.95
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Clinical Journal of the American Society of Nephrology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (5t32dk062711-05)
- U.S. Public Health Service (5R01-063020)
- National Institute of Diabetes and Digestive and Kidney Diseases (5T32DK062711)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Nephrology › Dialysis and Renal Disease Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Disease Prevention
- Keywords
- home blood pressure, hemodialysis, ambulatory blood pressure monitoring, cardiovascular mortality, all-cause mortality, prognostic value, self-measured blood pressure, interdialytic interval, systolic blood pressure, diastolic blood pressure, dose-response relationship
- MeSH terms
- Adult, Aged, Blood Pressure Determination, Cross-Sectional Studies, Female, Renal Dialysis, Humans, Male, Middle Aged, Prognosis, Prospective Studies, Self Care, Cohort Studies, Blood Pressure Monitoring, Ambulatory
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