Background—Damage to large arteries is a major factor in the high cardiovascular morbidity and mortality of patients with end-stage renal disease (ESRD). Increased arterial stiffness and intima-med...

Impact of Aortic Stiffness on Survival in End-Stage Renal Disease

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)60308-X.pdf

Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension.

The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2009)

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K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients.

https://www.kidney-international.org/article/S0085-2538(15)48948-3/pdf

Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients

Background. The prognosis of chronic dialysis patients is poor, in part due to the high incidence of cardiovascular disease. Malnutrition, such as hypoalbuminaemia, has been shown to be a predictor of death in this group of patients, while serum C-reactive protein (CRP) is a predictor of myocardial infarction and sudden death. Thus, the aim of the present study was to determine of the relationship between CRP and serum albumin concentration, and the value of baseline CRP data in the prediction of death. Methods. In one of the dialysis units in Okinawa, Japan, baseline CRP data was available (n=163, 95 men and 68 women) in January 1991. These patients were divided into two groups according to their baseline CRP levels, with group 1 consisting of CRP<10 mg/l (n=128) and group 2 of CRP≥10 mg/l (n=35), and then followed up until the end of 1997. Survival curves were calculated using the Kaplan-Meier method. The statistical significance of the relationship between CRP levels and the risk of death was evaluated by multiple logistic analysis with covariables such as age, sex, diabetes mellitus, serum albumin, and blood pressure. Results. The mean (SD) level of serum albumin was 38 (3) g/l in group 1 and 36 (3) g/l in group 2 (P<0.00001). The 5-year survival rate was significantly poorer in group 2 (44.4%) than in group 1 (82.5%) (P<0.0001). Furthermore, the risk of death was significantly higher in group 2 (relative risk 3.48 (95% confidence interval 1.76-6.89), P<0.0003) by multivariate Cox proportional hazard analysis. Conclusions. CRP is a significant predictor of death in chronic dialysis patients, independent of serum albumin and other possible confounders. Dialysis patients with high CRP levels should be carefully evaluated and monitored regardless of serum albumin concentrations in the normal range.

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Serum C-reactive protein (CRP) and risk of death in chronic dialysis patients

https://www.kidney-international.org/article/S0085-2538(15)60005-9/pdf

Low diastolic blood pressure, hypoalbuminemia, and risk of death in a cohort of chronic hemodialysis patients

Background. Prospective and case-control studies show that blood-pressure variability is an independent risk factor for severe organ damage and cardiovascular events in hypertensives. We prospectively studied the association between systolic blood pressure variability and cardiovascular mortality and mortality from all causes in end-stage renal disease patients. Methods and results. The subjects were 144 patients (86 men, 58 women; mean age±SD, 52±13 years) who underwent dialysis in the same dialysis centre and were examined for blood-pressure variability. The study period was 38 months beginning in January 1995, during which six cardiovascular and seven non-cardiovascular fatalities occurred. Coefficient of variation in systolic blood pressure in 1994, as an indicator of systolic blood pressure variability, ranged from 7.8 to 14.6%. Cumulative incidence of death from all causes was related to coefficient of variation in systolic blood pressure. The difference between the maximum and minimum systolic blood pressure (ASBP) in 1994 ranged from 44 to 146 mmHg (mean±SD, 78±13 mmHg) and correlated significantly with coefficient of variation in systolic blood pressure (r= 0.65, P<0.0001). Cox regression analysis was used to identify the independent predictors for mortality. The hazard ratio for death from all causes increased 1.63 times per 1% increase in coefficient of variation in systolic blood pressure (hazard ratio; 95% confidence interval: 1.63; 1.05-2.53) and 1.03 times per 1 mmHg increase in ASBP (1.08; 1.03-1.14). Conclusion. These results suggest that systolic blood pressure variability may be a significant prognostic factor in end-stage renal disease.

Blood pressure variability as an adverse prognostic risk factor in end-stage renal disease

Outcome study of renal biopsy patients in Okinawa, Japan

A high plasma aldosterone concentration (PAC) is known to be associated with poor outcome in patients with cardiac disease. However, the prognostic value of PAC in chronic hemodialysis (HD) patients is unknown. In 1996 we examined 128 hypertensive patients treated with antihypertensive drugs, excluding angiotensin-converting enzyme inhibitors, who were undergoing chronic HD (ages 61.8+/-13.8 years, 62% male), and for whom PAC (ng/dl) data were obtained. We followed up these patients until November 2003. During the follow-up period, 30 patients died. About half of all patients (48%) had PAC values above the normal range. We assigned the 128 patients to a lower ( or = 22.9) PAC group according to the median baseline PAC. The survival rate as calculated by the Kaplan-Meier method was 90.6% in the higher PAC group and 62.5% in the lower PAC group (p=0.003). In multivariate analysis, serum potassium and plasma renin activity were independent determinants of PAC. Cox proportional hazards analysis, with adjustment for other variables including diabetes, showed that lower PAC was independently predictive of death. The adjusted hazard ratio (95% confidence interval) of the lower PAC group was 2.905 (1.187-7.112, p=0.020). The significance of PAC became marginal by adjustment with albumin or potassium. These results indicate that higher PAC is common, but not associated with an increase in total and cardiovascular deaths among hypertensive patients undergoing chronic HD. The association between lower PAC and poor survival may be driven by volume retention and/or lower potassium.

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Shinichiro Yoshi

Papers

Serum C-reactive protein (CRP) and risk of death in chronic dialysis patients

Low diastolic blood pressure, hypoalbuminemia, and risk of death in a cohort of chronic hemodialysis patients

Blood pressure variability as an adverse prognostic risk factor in end-stage renal disease

Outcome study of renal biopsy patients in Okinawa, Japan

Plasma Aldosterone in Hypertensive Patients on Chronic Hemodialysis: Distribution, Determinants and Impact on Survival