03 December 2023: Clinical Research
Impact of Long-Term Blood Pressure Variability on Survival Rate in Elderly Maintenance Hemodialysis Patients: A 46-Month Follow-Up Study of 245 Patients
Yue Zhang1ABCDE, Daqing Hong1ABCDE, Qiang He1BCDE, Guisen Li1CDE, Hui Gao1AE*DOI: 10.12659/MSM.940621
Med Sci Monit 2023; 29:e940621
Abstract
BACKGROUND: At present, there are few blood pressure variability (BPV)-related studies of elderly maintenance hemodialysis (MHD) patients. This study aimed to compare the effects of long-term BPV on the 46-month survival rate of MHD patients aged <75 years and ≥75 years between 2000 and 2014, with follow-up until 2018.
MATERIAL AND METHODS: According to systolic blood pressure variability (SBPV) and diastolic blood pressure variability (DBPV), patients were divided into 4 groups: a low SBPV group (n=121), a high SBPV group (n=122), a low DBPV group (n=114), and a high DBPV group (n=112).
RESULTS: We included 243 patients in the study. All the patients were followed up for 46 months, and 59 patients (28 males) died during follow-up. The survival rate of patients in the high SBPV group was significantly lower than that of the low SBPV group (log rank P=0.049). No significant differences were observed between the high DBPV group and low DBPV group (log rank P=0.167). There were no significant differences in survival rates between the high SBPV group and low SBPV group among patients aged <75 years (log rank P=0.656), and among patients ≥75 years, the survival rate of the high SBPV group was significantly lower than that of the low SBPV group (log rank P=0.041).
CONCLUSIONS: Increased long-term SBPV in MHD patients is associated with a decrease in long-term survival rate, and patients ≥75 years are more susceptible to it.
Keywords: Hemodialysis, Home, Survival
Background
Hypertension is the leading cause of cardiovascular disease and premature death worldwide [1]. Hypertension occurs in 67–92% of patients with chronic kidney disease, which increases with the decline in glomerular filtration rate (GFR) [2]. Blood pressure variability (BPV) refers to the degree of blood pressure variations within a certain period of time, representing the dynamic and characteristic physiological characteristics of cardiovascular system function [3]. It can be divided into inter-cardiac cycle BPV, short-term BPV, and long-term BPV according to the length of observation time [4].
For dialysis patients, short-term variability often refers to the blood pressure variability during dialysis, while long-term variability refers to the degree of blood pressure fluctuations at the beginning of each dialysis session within a certain period of time [5,6]. The NHANES III study suggested that long-term systolic BPV is positively associated with all-cause mortality in the general population [7], and increased long-term BPV is associated with increased cardiovascular mortality in patients with type 2 diabetes [8]. The effects of short-term BPV on the prognosis in hemodialysis patients have been extensively studied. However, the effects of long-term BPV, particularly variability over many years, have been less studied in hemodialysis patients [9,10]. Blood volume fluctuations, vascular calcification, and autonomic dysfunction in maintenance hemodialysis (MHD) patients lead to large and unstable BPV and poor prognosis [11,12]. Greater pre-dialysis BPV among hemodialysis patients was reported to be associated with all-cause mortality [13,14]. At present, there is still some controversy regarding the effects of systemic hypertension on survival in hemodialysis patients [15,16]. Therefore, this retrospective study aimed to compare the effects of long-term systemic blood pressure variability on the 46-month survival rate of 245 patients aged <75 years and ≥75 years on maintenance hemodialysis between 2000 and 2014, with follow-up until 2018.
Material and Methods
ETHICS STATEMENT:
The study was approved by the Medical Ethics Committee of Sichuan Provincial People’s Hospital (2018-167). Written informed consent was obtained from each patient.
PATIENTS:
Patients who entered our center for MHD due to uremia from January 2000 to January 2014 were retrospectively included. The BP data were obtained before each dialysis session of patients from January 2014 to June 2014. Inclusion criteria were patients with: (1) dialysis received for ≥3 months and (2) aged ≥18 years. Exclusion criteria were patients with: (1) BP data records for less than 1 time/month and (2) incomplete BP records.
BPV MEASUREMENT:
BP was measured using a unified electronic sphygmomanometer (OMron HEM 7200) after at least 10 min of quiet rest for each dialysis patient upon arrival at the dialysis room. BP was measured again 5 min later and the was averaged twice.
BPV encompasses broad blood pressure changes that occur within seconds or minutes (very short-term BPV), over 24 h (short-term BPV), and between days (mid-term BPV) [17]. Long-term BPV were obtained from the standard deviation (SD) of BP from January 2014 to June 2014. Long-term BPV is expressed as standard deviation (SD) and was calculated by the following formula:
According to systolic blood pressure variability (SBPV) and diastolic blood pressure variability (DBPV), patients were divided into 4 groups: a low SBPV group, a high SBPV group, a low DBPV group, and a high DBPV group. Follow-up observation was conducted until April 30, 2018 and the end-point was death.
STATISTICAL ANALYSIS:
Statistical analyses were performed using SPSS version 17.0 (SPSS, Chicago, IL, U.S.A.). Quantitative data are described as mean±standard deviation (SD) or median (inter-quartile range). Categorical variables are presented as numbers (percentage). Normally distributed data were compared using the
Results
PARTICIPANT CHARACTERISTICS:
We selected 276 patients registered in the Hemodialysis Remote Terminal System of our center and who had received ≥3 months of MHD treatment. Among them, 10 patients were transferred to transplantation, 2 were transferred to peritoneal dialysis, 11 were transferred to other hospitals, and 10 cases were excluded due to incomplete registration data; the remaining 243 patients were included in the study. There were 121 cases of primary glomerular disease, 44 cases of diabetic nephropathy, 31 cases of hypertensive renal damage, 19 cases of polycystic kidney disease, and 28 cases of other primary diseases. All the patients were followed up for 46 months, and 59 patients (28 males) died during follow-up (Table 1).
SURVIVAL:
According to the median of SBPV (12.4 mmHg) and the median of DBPV (7.2 mmHg), patients were divided into 4 groups: a low SBPV group, a high SBPV group, a low DBPV group, and a high DBPV group. Survival analysis showed that the survival rate of patients in the high SBPV group was significantly lower than that of the low SBPV group (log rank P=0.049). No significant differences were observed between the high DBPV group and low DBPV group (log rank P=0.167) (Table 1, Figure 1).
There were no significant differences in survival rates between the high SBPV group and low SBPV group among patients aged <75 years (log rank P=0.656), and among patients ≥75 years, the survival rate of high SBPV group was significantly lower than that of the low SBPV group (log rank P=0.041) (Table 2, Figure 2A, 2B). There was no significant difference in survival rates between the high DBPV group and low DBPV group in patients aged <75 years (log rank P=0.875) and patients aged ≥75 years (log rank P=0.190) (Table 2, Figure 2C, 2D).
Discussion
LIMITATIONS OF THE STUDY:
The small sample size and short study duration are limitations of this study. Therefore, a multicenter, prospective clinical study with a large sample size and long-term follow-up is needed.
Conclusions
In conclusion, increased long-term SBPV in MHD patients is associated with a decrease in long-term survival rate, and patients ≥75 years are more susceptible to it.
Figures
Figure 1. The relationship between blood pressure variability (BPV) and survival time in maintenance hemodialysis (MHD) patients. (A) The relationship between systolic blood pressure variability (SBPV) and survival time. (B) The relationship between diastolic blood pressure variability (DBPV) and survival time. 
Figure 2. Maintenance hemodialysis (MHD) patients were grouped as patients aged <75 years and patients aged ≥75 years, and the relationship between BPV and survival time in each group is shown. (A) The relationship between systolic blood pressure variability (SBPV) and survival time of MHD patients <75 years. (B) The relationship between SBPV and survival time of MHD patients ≥75 years. (C) The relationship between diastolic blood pressure variability (DBPV) and survival time of MHD patients <75 years. (D) The relationship between DBPV and survival time of MHD patients ≥75 years. 
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Figures
Figure 1. The relationship between blood pressure variability (BPV) and survival time in maintenance hemodialysis (MHD) patients. (A) The relationship between systolic blood pressure variability (SBPV) and survival time. (B) The relationship between diastolic blood pressure variability (DBPV) and survival time.Figure 2. Maintenance hemodialysis (MHD) patients were grouped as patients aged <75 years and patients aged ≥75 years, and the relationship between BPV and survival time in each group is shown. (A) The relationship between systolic blood pressure variability (SBPV) and survival time of MHD patients <75 years. (B) The relationship between SBPV and survival time of MHD patients ≥75 years. (C) The relationship between diastolic blood pressure variability (DBPV) and survival time of MHD patients <75 years. (D) The relationship between DBPV and survival time of MHD patients ≥75 years. In Press
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