This Article Full Text Full Text (PDF) Data Supplement All Versions of this Article: 54/2/241    most recent HYPERTENSIONAHA.109.136366v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Google Scholar Articles by Agarwal, R. PubMed PubMed Citation Articles by Agarwal, R. Related Collections Other hypertension Clinical Studies Other etiology

(Hypertension. 2009;54:241.)
© 2009 American Heart Association, Inc.

Original Articles

Volume-Associated Ambulatory Blood Pressure Patterns in Hemodialysis Patients

From the Division of Nephrology and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Ind.

Correspondence to Rajiv Agarwal, Veterans Affairs Medical Center, 111N, 1481 West 10th St, Indianapolis, IN 46202. E-mail ragarwal{at}iupui.edu

Although volume excess causes hypertension, whether it also affects circadian patterns of arterial pressures among hemodialysis patients remains unknown. To test the notion of whether volume overload is associated with a unique blood pressure (BP) "signature," a posthoc analysis was performed among 145 patients participating in the Dry-Weight Reduction in Hypertensive Hemodialysis Patients randomized, controlled trial. Using 400 ambulatory BP recordings over 8 weeks composed of 35 302 measurements, the trended cosinor model was found to be the best descriptor of BP chronobiology. The trended cosinor model may be described as a pattern of sinusoidal oscillation around a straight line with an upward trend during the interdialytic period that has an intercept at the postdialysis time. Augmented volume removal therapy reduced the intercept systolic BP and increased the rate of rise in systolic BP over the interdialytic interval but had no effect on the systolic BP fluctuation (amplitude). Thus, an elevated intercept and blunted slope pattern characterize the "volume-overload BP pattern" on ambulatory BP monitoring. Similar changes were seen for diastolic BP. Augmented volume removal therapy neither restored dipping nor was associated with a lag phenomenon for either the wake or the sleep systolic BP. Lowering of systolic BP was greater than diastolic BP such that pulse pressure was reduced. An observational cohort of 37 patients followed for 6 months confirmed these findings. Randomized trials are now needed to evaluate the clinical impact of augmented volume removal therapy on hard outcomes, because reduction of pulse pressure with this simple expedient has the potential to improve survival in hemodialysis patients.

Key Words: hypertension • hemodialysis • ambulatory blood pressure monitoring • blood volume • chronobiology phenomena