title: Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality.
abstract: 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.
  
  
  METHODS
  Observational study.
  
  
  METHODS
  17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years.
  
  
  METHODS
  Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to ≥160mmHg in 10-mmHg increments) and 5 (<60 to ≥90mmHg in 10-mmHg increments) categories, respectively, and as continuous measures.
  
  
  METHODS
  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±10.6mmHg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP<140mmHg. 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) mmHg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa; Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
authors.forename: Keiichi
authors.initials: K
authors.lastname: Sumida
authors.affiliation: Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.
authors.forename: Miklos Z
authors.initials: MZ
authors.lastname: Molnar
authors.affiliation: Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN.
authors.forename: Praveen K
authors.initials: PK
authors.lastname: Potukuchi
authors.affiliation: Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN.
authors.forename: Fridtjof
authors.initials: F
authors.lastname: Thomas
authors.affiliation: Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN.
authors.forename: Jun Ling
authors.initials: JL
authors.lastname: Lu
authors.affiliation: Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange.
authors.forename: Vanessa A
authors.initials: VA
authors.lastname: Ravel
authors.affiliation: Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange.
authors.forename: Melissa
authors.initials: M
authors.lastname: Soohoo
authors.affiliation: Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange.
authors.forename: Connie M
authors.initials: CM
authors.lastname: Rhee
authors.affiliation: Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange.
authors.forename: Elani
authors.initials: E
authors.lastname: Streja
authors.affiliation: Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
authors.forename: John J
authors.initials: JJ
authors.lastname: Sim
authors.affiliation: Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
authors.forename: Kunihiro
authors.initials: K
authors.lastname: Yamagata
authors.affiliation: Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange.
authors.forename: Kamyar
authors.initials: K
authors.lastname: Kalantar-Zadeh
authors.affiliation: Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis VA Medical Center, Memphis, TN. Electronic address: ckovesdy@uthsc.edu.
authors.forename: Csaba P
authors.initials: CP
authors.lastname: Kovesdy
mesh_terms: D000368:Aged; D001794:Blood Pressure; D001795:Blood Pressure Determination; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy; D008297:Male; D006435:Renal Dialysis / Q000401:mortality*; D012189:Retrospective Studies; D013997:Time Factors; D014481:United States; D058014:Veterans Health
keywords: Blood pressure (BP); chronic kidney disease (CKD); dialysis; dialysis initiation; diastolic BP (DBP); end-stage renal disease (ESRD); incident ESRD; mortality; reverse epidemiology; risk factor paradox; systolic BP (SBP); transition; transition of care