Abstract
Visit-to-visit blood pressure variability (VTV-BPV) is an independent risk factor for cardiovascular events and death in the general population. We sought to determine the association of VTV-BPV with outcomes in patients on hemodialysis, using data from a National Institutes of Health-sponsored randomized trial (the HEMO study). We used the coefficient of variation (CV) and the average real variability in systolic blood pressure (SBP) as metrics of VTV-BPV. In all, 1844 out of 1846 randomized subjects had at least three visits with SBP measurements and were included in the analysis. Median follow-up was 2.5 years (interquartile range 1.3–4.3 years), during which time there were 869 deaths from any cause and 408 (adjudicated) cardiovascular deaths. The mean pre-dialysis SBP CV was 9.9±4.6%. In unadjusted models, we found a 31% higher risk of death from any cause per 10% increase in VTV-BPV. This association was attenuated after multivariable adjustment but remained statistically significant. Similarly, we found a 28% higher risk of cardiovascular death per 10% increase in VTV-BPV, which was attenuated and no longer statistically significant in fully adjusted models. The associations among VTV-BPV, death and cardiovascular death were modified by baseline SBP. In a diverse, well-dialyzed cohort of patients on maintenance hemodialysis, VTV-BPV, assessed using metrics of variability in pre-dialysis SBP, was associated with a higher risk of all-cause mortality and a trend toward higher risk of cardiovascular mortality, particularly in patients with a lower baseline SBP.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 digital issues and online access to articles
$119.00 per year
only $9.92 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Lewington S, Clarke R, Qizilbash N, Peto R, Collins R and Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. The Lancet 2002; 360 (9349): 1903–1913.
Weiss JW, Johnson ES, Petrik A, Smith DH, Yang X, Thorp ML . Systolic blood pressure and mortality among older community-dwelling adults with CKD. Am J Kidney Dis 2010; 56 (6): 1062–1071.
Zager PG, Nikolic J, Brown RH, Campbell MA, Hunt WC, Peterson D et al. ‘U’ curve association of blood pressure and mortality in hemodialysis patients. Medical directors of dialysis clinic, inc. Kidney Int 1998; 54 (2): 561–569.
Li Z, Lacson E Jr, Lowrie EG, Ofsthun NJ, Kuhlmann MK, Lazarus JM et al. The epidemiology of systolic blood pressure and death risk in hemodialysis patients. Am J Kidney Dis 2006; 48 (4): 606–615.
Chang TI, Friedman GD, Cheung AK, Greene T, Desai M, Chertow GM . Systolic blood pressure and mortality in prevalent haemodialysis patients in the hemo study. J Hum Hypertens 2011; 25 (2): 98–105.
Mancia G . Blood pressure variability at normal and high blood pressure. Chest 1983; 83 (2 Suppl): 317–320.
Rossignol P, Cridlig J, Lehert P, Kessler M, Zannad F . Visit-to-visit blood pressure variability is a strong predictor of cardiovascular events in hemodialysis/novelty and significance. Hypertension 2012; 60 (2): 339–346.
Brunelli SM, Thadhani RI, Lynch KE, Ankers ED, Joffe MM, Boston R et al. Association between long-term blood pressure variability and mortality among incident hemodialysis patients. Am J Kidney Dis 2008; 52 (4): 716–726.
Brueren MM, Limpt PV, Schouten HJA, de Leeuw PW, van Ree JW . Is a series of blood pressure measurements by the general practitioner or the patient a reliable alternative to ambulatory blood pressure measurement? Am J Hypertens 1997; 10 (8): 879–885.
Howard SC, Rothwell PM . Reproducibility of measures of visit-to-visit variability in blood pressure after transient ischaemic attack or minor stroke. Cerebrovasc Dis 2009; 28 (4): 331–340.
Muntner P, Shimbo D, Tonelli M, Reynolds K, Arnett DK, Oparil S . The relationship between visit-to-visit variability in systolic blood pressure and all-cause mortality in the general population. Hypertension 2011; 57 (2): 160–166.
Rothwell PM, Howard SC, Dolan E, O'Brien E, Dobson JE, Dahlöf B et al. Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. The Lancet 2010; 375 (9718): 895–905.
Rothwell PM . Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension. The Lancet 2010; 375 (9718): 938–948.
Kikuya M, Ohkubo T, Metoki H, Asayama K, Hara A, Obara T et al. Day-by-day variability of blood pressure and heart rate at home as a novel predictor of prognosis. Hypertension 2008; 52 (6): 1045–1050.
Pringle E, Phillips C, Thijs L, Davidson C, Staessen JA, de Leeuw PW et al. Systolic blood pressure variability as a risk factor for stroke and cardiovascular mortality in the elderly hypertensive population. J Hypertens 2003; 21 (12): 2251–2257.
Mancia G, Bombelli M, Facchetti R, Madotto F, Corrao G, Trevano FQ et al. Long-term prognostic value of blood pressure variability in the general population. Hypertension 2007; 49 (6): 1265–1270.
Farrell B, Godwin J, Richards S, Warlow C . The united kingdom transient ischaemic attack (uk-tia) aspirin trial: Final results. J Neurol Neurosurg Psychiatry 1991; 54 (12): 1044–1054.
Greene T, Beck GJ, Gassman JJ, Gotch FA, Kusek JW, Levey AS et al. Design and statistical issues of the hemodialysis (hemo) study. Control Clin Trials 2000; 21 (5): 502–525.
Eknoyan G, Beck GJ, Cheung AK, Daugirdas JT, Greene T, Kusek JW et al. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med 2002; 347 (25): 2010–2019.
Miskulin DC, Athienites NV, Yan G, Martin AA, Ornt DB, Kusek JW et al. Comorbidity assessment using the index of coexistent diseases in a multicenter clinical trial. Kidney Int 2001; 60 (4): 1498–1510.
Mena L, Pintos S, Queipo NV, Aizpurua JA, Maestre G, Sulbaran T . A reliable index for the prognostic significance of blood pressure variability. J Hypertens 2005; 23 (3): 505–511.
Vittinghoff E, Glidden DV, Shiboski SC, McCulloch CE . Generalized linear models. In Regression Methods in Biostatistics: Linear, Logistic, Survival, and Repeated Measures Models. Springer Science: New York, pp 291–303 2005.
Durrleman S, Simon R . Flexible regression models with cubic splines. Stat Med 1989; 8 (5): 551–561.
Di Iorio B, Di Micco L, Torraca S, Sirico ML, Guastaferro P, Chiuchiolo L et al. Variability of blood pressure in dialysis patients: a new marker of cardiovascular risk. J Nephrol 2013; 26 (1): 173–182.
Tozawa M, Iseki K, Yoshi S, Fukiyama K . Blood pressure variability as an adverse prognostic risk factor in end-stage renal disease. Nephrol Dial Transplant 1999; 14 (8): 1976–1981.
Kawai T, Ohishi M, Kamide K, Onishi M, Takeya Y, Tatara Y et al. The impact of visit-to-visit variability in blood pressure on renal function. Hypertens Res 2011; 35 (2): 239–243.
Asayama K, Kikuya M, Schutte R, Thijs L, Hosaka M, Satoh M et al. Home blood pressure variability as cardiovascular risk factor in the population of ohasama. Hypertension 2013; 61 (1): 61–69.
Di Iorio B, Pota A, Sirico ML, Torraca S, Di Micco L, Rubino R et al. Blood pressure variability and outcomes in chronic kidney disease. Nephrol Dial Transplant 2012; 27 (12): 4404–4410.
Mancia G, Facchetti R, Parati G, Zanchetti A . Visit-to-visit blood pressure variability, carotid atherosclerosis, and cardiovascular events in the european lacidipine study on atherosclerosis/ clinical perspective. Circulation 2012; 126 (5): 569–578.
O'Hare AM, Choi AI, Bertenthal D, Bacchetti P, Garg AX, Kaufman JS et al. Age affects outcomes in chronic kidney disease. J Am Soc Nephrol 2007; 18 (10): 2758–2765.
Webb AJ, Fischer U, Mehta Z, Rothwell PM . Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: A systematic review and meta-analysis. Lancet 2010; 375 (9718): 906–915.
Hsieh YT, Tu ST, Cho TJ, Chang SJ, Chen JF, Hsieh MC . Visit-to-visit variability in blood pressure strongly predicts all-cause mortality in patients with type 2 diabetes: A 5.5-year prospective analysis. Eur J Clin Invest 2012; 42 (3): 245–253.
Okada H, Fukui M, Tanaka M, Matsumoto S, Mineoka Y, Nakanishi N et al. Visit-to-visit blood pressure variability is a novel risk factor for the development and progression of diabetic nephropathy in patients with type 2 diabetes. Diabetes Care, (e-pub ahead of print 22 January 2013).
Muntner P, Levitan EB, Joyce C, Holt E, Mann D, Oparil S et al. Association between antihypertensive medication adherence and visit-to-visit variability of blood pressure. J Clin Hypertens 2013; 15 (2): 112–117.
Acknowledgements
Dr Chang is funded by an American Heart Association National Scientist Development Grant (SDG11670032). Dr Chertow is supported by NIDDK K24 085446. The HEMO study was conducted by the HEMO study Investigators and supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). This manuscript does not necessarily reflect the opinions or views of HEMO study or the NIDDK.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
The authors declare no conflict of interest.
Additional information
Supplementary Information accompanies this paper on the Journal of Human Hypertension website
Supplementary information
Rights and permissions
About this article
Cite this article
Chang, T., Flythe, J., Brunelli, S. et al. Visit-to-visit systolic blood pressure variability and outcomes in hemodialysis. J Hum Hypertens 28, 18–24 (2014). https://doi.org/10.1038/jhh.2013.49
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/jhh.2013.49
Keywords
This article is cited by
-
Effect of patient gender on short-term blood pressure variability in hemodialysis patients
Journal of Human Hypertension (2022)
-
Changes in pre-dialysis blood pressure variability in the first year of dialysis associate with mortality in European hemodialysis patients: a retrospective cohort study on behalf of the MONDO Initiative
Journal of Human Hypertension (2021)
-
Intradialytic systolic blood pressure variation can predict long-term mortality in patients on maintenance hemodialysis
International Urology and Nephrology (2021)
-
Nebivolol reduces short-term blood pressure variability more potently than irbesartan in patients with intradialytic hypertension
Hypertension Research (2019)
-
Characteristics of visit-to-visit blood pressure variability in hemodialysis patients
Hypertension Research (2019)