title: Ultrafiltration intensification in hemodialysis patients improves hypertension but increases AV fistula complications and cardiovascular events.
abstract: BACKGROUND
  Hypertension remains a major problem in hemodialysis (HD) patients.
  
  
  METHODS
  We performed a pragmatic trial (Pragmatic Clinical Intervention on Blood Pressure Driven by Audit [CLINIDEA]) testing the effectiveness and safety of a 6-month multimodal intervention in hypertensive HD patients regarding the application of higher ultrafiltration (UF) rates or longer or more frequent dialyses in UF-intolerant patients, and an educational intervention to encourage patients to lower their salt and fluid intake.
  
  
  RESULTS
  Blood pressure (BP) in hypertensive patients (n=32) fell from 156.8 ± 13.3 / 81.1 ± 8.9 mm Hg to 147.9 ± 18.8 / 77.5 ± 11.1 mm Hg. UF intensification was well tolerated, and the BP goal was achieved without resorting to longer or more frequent dialyses. BP changes were paralleled by a consistent (p<0.01) fall in dry body weight. The trial largely failed at increasing compliance with salt prescription (salt intake: baseline: 156.9 ± 64 mEq/day, 6-month: 150.7 ± 60.3 mEq/day). During the 12 months preceding the trial, the hospitalization rates for arteriovenous (AV) fistula complications and cardiovascular (CV) events were identical in hypertensive and in normotensive patients. However, these complications selectively increased (AV complications: relative risk [RR] = 7.6; CV complication: RR=8.4) in hypertensive patients coinciding with UF intensification during the trial. Increasing the UF rate is an effective BP-lowering intervention in HD patients. However, this intervention is associated with a higher risk for AV complications and CV events.
  
  
  CONCLUSIONS
  Longer and/or more frequent dialyses and better efforts to increase compliance to low salt diets than those put in place in this study are needed to reduce the high prevalence of hypertension in the HD population.
authors.affiliation: Nephrology, Dialysis and Renal Transplantation Unit and CNR-IBIM Clinical epidemiology and Pathophysiology of Renal Diseases and Hypertension, United Hospitals, Reggio Calabria, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Curatola
authors.forename: Davide
authors.initials: D
authors.lastname: Bolignano
authors.forename: Stefania
authors.initials: S
authors.lastname: Rastelli
authors.forename: Graziella
authors.initials: G
authors.lastname: Caridi
authors.forename: Rocco
authors.initials: R
authors.lastname: Tripepi
authors.forename: Giovanni
authors.initials: G
authors.lastname: Tripepi
authors.forename: Raffaele
authors.initials: R
authors.lastname: Politi
authors.forename: Francesco
authors.initials: F
authors.lastname: Catalano
authors.forename: Diego
authors.initials: D
authors.lastname: Delfino
authors.forename: Maurizio
authors.initials: M
authors.lastname: Ciccarelli
authors.forename: Francesca
authors.initials: F
authors.lastname: Mallamaci
authors.forename: Carmine
authors.initials: C
authors.lastname: Zoccali
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D001794:Blood Pressure / Q000502:physiology; D002318:Cardiovascular Diseases / Q000150:complications / Q000503:physiopathology; D004039:Diet, Sodium-Restricted; D045604:Extracellular Fluid / Q000502:physiology; D005260:Female; D017583:Hemodiafiltration / Q000009:adverse effects* / Q000379:methods; D006760:Hospitalization; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000178:diet therapy / Q000503:physiopathology / Q000628:therapy*; D007676:Kidney Failure, Chronic / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic; D006435:Renal Dialysis / Q000379:methods