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Klassen PS, Lowrie EG, Reddan DN, et al. Association Between Pulse Pressure and Mortality in Patients Undergoing
Maintenance Hemodialysis. JAMA. 2002;287(12):1548–1555. doi:10.1001/jama.287.12.1548
Author Affiliations: Duke Institute of Renal Outcomes Research and Health Policy, Department of Medicine, Duke University Medical Center (Drs Klassen, Lowrie, Reddan, Coladonato, Szczech, and Owen) and Duke Clinical Research Institute (Dr DeLong), Durham, NC; and Fresenius Medical Care, North America, Lexington, Mass (Drs Lowrie and Lazarus); Dr Owen now works at Baxter Healthcare International, Waukegan, Ill.
Context Although increased blood pressure is associated with adverse outcomes
in the general population, elevated blood pressure is associated with decreased
mortality in patients with end-stage renal disease undergoing maintenance
hemodialysis. Recent investigations in the general population have demonstrated
the predictive utility of pulse pressure (systolic minus diastolic blood pressure),
a measure reflecting the pulsatile nature of the cardiac cycle.
Objectives To estimate the relationship between pulse pressure and mortality in
patients undergoing maintenance hemodialysis and to test our hypothesis that
an increasing pulse pressure would be associated with increased risk of death
up to 1 year despite the inverse relationship between conventional blood pressure
measures and mortality in patients with end-stage renal disease.
Design, Setting, and Patients Retrospective cohort investigation of patients with end-stage renal
disease undergoing maintenance hemodialysis at 782 hemodialysis facilities
throughout the United States. Of 44 069 eligible patients as of January
1, 1998, 37 069 with complete demographic data were included in the analyses
of clinical and laboratory data collected from October 1 through December
31, 1997. Patients were followed up through December 31, 1998.
Main Outcome Measures The primary study outcome was death at 1 year. A secondary outcome was
the magnitude of the pulse pressure.
Results The final patient cohort was similar to national averages with respect
to age, sex, race, and diabetic status. Mean (SD) pulse pressures before dialysis
were 75.0 (15.0) mm Hg and 66.9 (13.9) mm Hg after dialysis. By the end of
the 1-year follow-up, 5731 patients (18.4%) died. After adjusting for level
of systolic blood pressure, multivariable Cox proportional hazards modeling
showed a direct and consistent relationship between increasing pulse pressure
and increasing death risk. Each incremental elevation of 10 mm Hg in postdialysis
pulse pressure was associated with a 12% increase in the hazard for death
(hazard ratio, 1.12; 95% confidence interval, 1.06-1.18). Postdialysis systolic
blood pressure was inversely related to mortality with a 13% decreased hazard
for death for each incremental elevation of 10 mm Hg (hazard ratio, 0.87;
95% confidence interval, 0.84-0.90). In a multivariable linear regression
model, important variables directly associated with elevated pulse pressure
included age, diabetes, white race, female sex, and number of years receiving
dialysis (all P<.001).
Conclusions Pulse pressure is associated with risk of death in a large, nationally
representative sample of patients undergoing maintenance hemodialysis. The
recognition of pulse pressure as an important correlate of mortality in patients
receiving dialysis highlights the need to investigate the relationship between
potential therapeutic implications of conduit vessel function and clinical
outcomes in patients with end-stage renal disease.
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