Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality

作者：Sumida Keiichi; Molnar Miklos Z; Potukuchi Praveen K; Thomas Fridtjof; Lu Jun Ling; Ravel Vanessa A; Soohoo Melissa; Rhee Connie M; Streja Elani; Sim John J; Yamagata Kunihiro; Kalantar Zadeh Kamyar; Kovesdy Csaba P^*

来源：American Journal of Kidney Diseases, 2017, 70(2): 207-217.

DOI：10.1053/j.ajkd.2016.12.020

• Blood pressure (BP)
• mortality
• chronic kidney disease (CKD)
• dialysis
• transition
• dialysis initiation
• end-stage renal disease (ESRD)
• incident ESRD
• systolic BP (SBP)
• diastolic BP (DBP)
• transition of care
• reverse epidemiology
• risk factor paradox

Background: Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown.
Study Design: Observational study.
Setting & Participants: 17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years.
Predictor: Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to >= 160 mm Hg in 10-mm Hg increments) and 5 (<60 to >= 90 mm Hg in 10-mm Hg increments) categories, respectively, and as continuous measures.
Outcomes & Measurements: Postdialysis all-cause mortality, assessed over different follow-up periods (ie, <3, 3-<6, 6-<12, and >= 12 months after dialysis therapy initiation) using Cox regressions adjusted for demographics, comorbid conditions, medications, cardiovascular medication adherence, body mass index, estimated glomerular filtration rate, and type of vascular access.
Results: Mean predialysis SBP and DBP were 141.2 +/- 16.1 (SD) and 73.7 +/- 10.6 mm Hg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP < 140 mm Hg. Mortality risks associated with lower SBP were greatest in the first 3 months after dialysis therapy initiation, with multivariable-adjusted HRs of 2.40 (95% CI, 1.96-2.93), 1.99 (95% CI, 1.66-2.40), 1.35 (95% CI, 1.13-1.62), 0.98 (95% CI, 0.78-1.22), and 0.76 (95% CI, 0.57-1.00) for SBP <120, 120 to <130, 130 to <140, 150 to <160, and >= 160 (vs 140-<150) mm Hg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality.
Limitations: Results cannot be inferred to show causality and may not be generalizable to women or the general US population.
Conclusions: Lower predialysis SBP is associated with higher all-cause mortality in the immediate postdialysis period. Predialysis DBP showed no consistent association with postdialysis mortality. Further studies are needed to clarify ideal predialysis SBP levels among incident dialysis patients as a potential means to improve the excessively high early dialysis mortality. Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc. This is a US Government Work. There are no restrictions on its use.

• 出版日期2017-8