title: Blood pressure and risk of all-cause mortality in advanced chronic kidney disease and hemodialysis: the chronic renal insufficiency cohort study.
abstract: Studies of hemodialysis patients have shown a U-shaped association between systolic blood pressure (SBP) and mortality. These studies have largely relied on dialysis-unit SBP measures and have not evaluated whether this U-shape also exists in advanced chronic kidney disease, before starting hemodialysis. We determined the association between SBP and mortality at advanced chronic kidney disease and again after initiation of hemodialysis. This was a prospective study of Chronic Renal Insufficiency Cohort participants with advanced chronic kidney disease followed through initiation of hemodialysis. We studied the association between SBP and mortality when participants (1) had an estimated glomerular filtration rate <30 mL/min/1.73 m2 (n=1705), (2) initiated hemodialysis and had dialysis-unit SBP measures (n=403), and (3) initiated hemodialysis and had out-of-dialysis-unit SBP measured at a Chronic Renal Insufficiency Cohort study visit (n=326). Cox models were adjusted for demographics, cardiovascular risk factors, and dialysis parameters. A quadratic term for SBP was included to test for a U-shaped association. At advanced chronic kidney disease, there was no association between SBP and mortality (hazard ratio, 1.02 [95% confidence interval, 0.98-1.07] per every 10 mm Hg increase). Among participants who started hemodialysis, a U-shaped association between dialysis-unit SBP and mortality was observed. In contrast, there was a linear association between out-of-dialysis-unit SBP and mortality (hazard ratio, 1.26 [95% confidence interval, 1.14-1.40] per every 10 mm Hg increase). In conclusion, more efforts should be made to obtain out-of-dialysis-unit SBP, which may merit more consideration as a target for clinical management and in interventional trials.
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.). nbansal@nephrology.washington.edu.
authors.forename: Nisha
authors.initials: N
authors.lastname: Bansal
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Charles E
authors.initials: CE
authors.lastname: McCulloch
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Mahboob
authors.initials: M
authors.lastname: Rahman
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: John W
authors.initials: JW
authors.lastname: Kusek
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Amanda H
authors.initials: AH
authors.lastname: Anderson
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Dawei
authors.initials: D
authors.lastname: Xie
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Raymond R
authors.initials: RR
authors.lastname: Townsend
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Claudia M
authors.initials: CM
authors.lastname: Lora
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Jackson
authors.initials: J
authors.lastname: Wright
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Alan S
authors.initials: AS
authors.lastname: Go
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Akinlolu
authors.initials: A
authors.lastname: Ojo
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Arnold
authors.initials: A
authors.lastname: Alper
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Eva
authors.initials: E
authors.lastname: Lustigova
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Magda
authors.initials: M
authors.lastname: Cuevas
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Radhakrishna
authors.initials: R
authors.lastname: Kallem
authors.affiliation: From the Department of Medicine, Kidney Research Institute, University of Washington, Seattle (N.B.); Departments of Biostatistics and Epidemiology (C.E.M.) and Medicine (C.-y.H.), University of California, San Francisco; Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R., J.W.); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (J.W.K.); Departments of Epidemiology and Biostatistics (A.H.A.), Biostatistics (D.X.), and Medicine (R.R.T., M.C., R.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Medicine, University of Chicago, IL (C.M.L.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); Department of Medicine, University of Michigan, Ann Arbor (A.O.); and Department of Medicine, Tulane University, New Orleans, LA (A.A., E.L.).
authors.forename: Chi-Yuan
authors.initials: CY
authors.lastname: Hsu
mesh_terms: D000328:Adult; D000368:Aged; D001794:Blood Pressure / Q000502:physiology*; D002318:Cardiovascular Diseases / Q000453:epidemiology* / Q000209:etiology / Q000503:physiopathology; D002423:Cause of Death / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000150:complications / Q000401:mortality* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D006435:Renal Dialysis; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: CKD; ESRD; dialysis; hypertension; mortality