Assessment and Management of Hypertension among Patients on Peritoneal Dialysis

Transition between peritoneal dialysis modalities: Impact on blood pressure levels and drug prescription in a national multicentric cohort

BACKGROUND

Hypertension is a leading cause of kidney failure, affects most dialysis patients and associates with adverse outcomes. Hypertension can be difficult to control with dialysis modalities having differential effects on sodium and water removal. There are two main types of peritoneal dialysis (PD), automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). It is unknown whether one is superior to the other in controlling blood pressure (BP). Therefore, the aim of our study was to analyse the impact of switching between these two PD modalities on BP levels in a nationally representative cohort.

METHODS

This was a cohort study of patients on PD from 122 dialysis centres in Brazil (BRAZPD II study). Clinical and laboratory data were collected monthly throughout the study duration. We selected all patients who remained on PD at least 6 months and 3 months on each modality at minimum. We compared the changes in mean systolic/diastolic blood pressures (SBP/DBP) before and after modality transition using a multilevel mixed-model where patients were at first level and their clinics at the second level.

RESULTS

We analysed data of 848 patients (814 starting on CAPD and 34 starting on APD). The SBP decreased by 4 (SD 22) mmHg when transitioning from CAPD to APD (p < 0.001) and increased by 4 (SD 21) mmHg when transitioning from APD to CAPD (p = 0.38); consistent findings were seen for DBP. There was no significant change in the number of antihypertensive drugs prescribed before and after transition.

CONCLUSIONS

Transition between PD modalities seems to directly impact on BP levels. Further studies are needed to confirm if switching to APD could be an effective treatment for uncontrolled hypertension among CAPD patients.

The superiority of bioimpedance vs. echocardiography and pitting edema in predicting automated office blood pressure in continuous ambulatory peritoneal dialysis patients

INTRODUCTION

To achieve optimal blood pressure control in continuous ambulatory peritoneal dialysis (CAPD) patients, identifying methods of volume assessment with the strongest correlation with blood pressure is essential.

METHODS

In this cross-sectional study, 52 CAPD patients were assigned to automated office blood pressure (AOBP) measurement, assessment of pedal pitting edema, bioimpedance analysis (BIA), and inferior vena cava collapsibility index (IVCCI%) measurement. Data were analyzed using STATA ver.17, and the significance level was p < 0.05.

RESULTS

Fifty-two patients were divided based on their AOBP readings. 29 (55.8%) of patients had uncontrolled AOBP. Overhydration (OH) and the grade of pitting edema were significantly higher in the uncontrolled AOBP group. OH was identified as the best variable for predicting blood pressure (p ≤ 0.001) and detecting uncontrolled blood pressure (AUC = 0.832) using multivariate linear regression and ROC analysis, respectively.

CONCLUSION

BIA-derived OH was the best variable for predicting systolic and diastolic AOBP, outperforming IVCCI% and pitting edema.

Home-Based Dialysis: A Primer for the Internist

Home-based dialysis modalities offer both clinical and practical advantages to patients. The use of the home-based modalities, peritoneal dialysis and home hemodialysis, has been increasing over the past decade after a long period of decline. Given the increasing frequency of use of these types of dialysis, it is important for clinicians to be familiar with how these types of dialysis are performed and key clinical aspects of care related to their use in patients with end-stage kidney disease.

Diagnosis and treatment of hypertension in dialysis patients: a systematic review

In patients with end-stage renal disease (ESRD) undergoing dialysis, hypertension is common but often inadequately controlled. The prevalence of hypertension varies widely among studies because of differences in the definition of hypertension and the methods of used to measure blood pressure (BP), i.e., peri-dialysis or ambulatory BP monitoring (ABPM). Recently, ABPM has become the gold standard for diagnosing hypertension in dialysis patients. Home BP monitoring can also be a good alternative to ABPM, emphasizing BP measurement outside the hemodialysis (HD) unit. One thing for sure is pre- and post-dialysis BP measurements should not be used alone to diagnose and manage hypertension in dialysis patients. The exact target of BP and the relationship between BP and all-cause mortality or cause-specific mortality are unclear in this population. Many observational studies with HD cohorts have almost universally reported a U-shaped or even an L-shaped association between BP and all-cause mortality, but most of these data are based on the BP measured in HD units. Some data with ABPM have shown a linear association between BP and mortality even in HD patients, similar to the general population. Supporting this, the results of meta-analysis have shown a clear benefit of BP reduction in HD patients. Therefore, further research is needed to determine the optimal target BP in the dialysis population, and for now, an individualized approach is appropriate, with particular emphasis on avoiding excessively low BP. Maintaining euvolemia is of paramount importance for BP control in dialysis patients. Patient heterogeneity and the lack of comparative evidence preclude the recommendation of one class of medication over another for all patients. Recently, however, β-blockers could be considered as a first-line therapy in dialysis patients, as they can reduce sympathetic overactivity and left ventricular hypertrophy, which contribute to the high incidence of arrhythmias and sudden cardiac death. Several studies with mineralocorticoid receptor antagonists have also reported promising results in reducing mortality in dialysis patients. However, safety issues such as hyperkalemia or hypotension should be further evaluated before their use.

Peritoneal Dialysis Care in Mainland China: Nationwide Survey

BACKGROUND

Peritoneal dialysis (PD) care in mainland China has been progressing in the past 10 years.

OBJECTIVE

To complement information from the dialysis registry, a large-scale nationwide survey was conducted to investigate the current infrastructure and management of PD care at hospitals of different tiers.

METHODS

A web-based multiple-choice questionnaire was distributed through the National Center for Nephrology Medical Quality Management and Control to PD centers of secondary and tertiary hospitals in October 2020. The 2-part survey collected the information of PD centers and the clinical management of patients on PD. A total of 788 effective surveys from 746 hospitals were voluntarily returned, and data were extracted and analyzed.

RESULTS

The effective survey data covered 101,537 patients on PD, with 95% (96,460/101,537) in the tertiary hospitals. The median number of patients per PD center was 60 (IQR 21-152); this number was 32 (IQR 8-65) and 70 (IQR 27-192) for secondary and tertiary hospitals, respectively. There was a discrepancy in the availability of designated physical areas for different functions of PD care between the secondary and tertiary hospitals. The proportion of tertiary hospitals with PD training (P=.01), storage (P=.09), and procedure area (P<.001) was higher compared to secondary hospitals. PD catheter placement was performed in 96% (608/631) of the PD centers in tertiary hospitals, which was significantly higher compared to 86% (99/115) in secondary hospitals (P<.001). Automated PD was available in 55% (347/631) of the tertiary hospitals, which was significantly higher than that in secondary hospitals (37/115, 32%) according to the survey (P<.001). The most commonly performed PD module was continuous ambulatory peritoneal dialysis (772/788, 98%), followed by intermittent peritoneal dialysis (543/788, 69%). The overall reported nocturnal intermittent peritoneal dialysis was 31% (244/788); it was 28% (220/788) for continuous cycling peritoneal dialysis and 15% (118/788) for tidal peritoneal dialysis. Comparisons between the secondary and tertiary hospitals revealed no significant differences in prophylactic antibiotic use for PD catheter placement and therapeutic use for peritonitis. The first peritoneal equilibrium test was conducted in 58% (454/788) of patients at 4-6 weeks after initiation of PD, and 91% (718/788) reported at least one peritoneal equilibrium test per year. Overall, 79% (570/722) and 65% (469/722) of PD centers performed assessment for dialysis adequacy and residual kidney function, respectively; and 87% (685/788) of patients on PD were followed every 1 to 3 months for laboratory and auxiliary examinations.

CONCLUSIONS

This national survey reflects the current status and disparities of PD center management in mainland China. The study results suggest that the PD care needs to be more conveniently accessible in secondary hospitals, and quality management and staff training in secondary hospitals are still in high demand.

The significance of volume overload in the development of pulmonary arterial hypertension in continuous ambulatory peritoneal dialysis patients

INTRODUCTION

The underlying pathophysiology of pulmonary arterial hypertension (PAH) is multifactorial; however, the significance of chronic volume overload and its subsequent effects on cardiac function must be studied thoroughly. The main objective of this study was to determine the predictive parameters of PAH in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) using transthoracic echocardiography (TTE) and bioimpedance analysis (BIA).

METHODS

In this cross-sectional study, 43 eligible CAPD patients were chosen. The patients were examined by TTE and BIA before the morning dialysis session, and baseline patient characteristics, echocardiography, and BIA parameters were recorded.

RESULTS

Sixteen (37.2%) patients were diagnosed with PAH. Patients with PAH had significantly greater left atrial diameter (LAD), left ventricular mass index (LVMI), and higher grades of diastolic dysfunction (DDF). Systolic pulmonary artery pressure (sPAP) correlated with LAD (p < 0.001, r = 0.566), interventricular septal diameter (IVSD) (p = 0.004, r = 0.425), LVMI (p = 0.030, r = 0.323), and extracellular water/total body water (ECW/TBW) ratio (p = 0.002, r = 0.458).

CONCLUSION

Two volume status-related parameters including ECW/TBW ratio and inferior vena cava (IVC) expiratory diameter, and cardiac-related TTE findings such as LAD and DDF were predictors of sPAP in CAPD patients.

Comparison of soluble suppression of tumorigenicity 2 and brachial hemodynamic parameters between dialysis modalities in patients with end-stage kidney disease

PURPOSE

Major cardiovascular events (MACE) are the leading cause of mortality in patients with chronic kidney disease. Although hemodialysis (HD) and peritoneal dialysis (PD) are comparable in survival, patients with HD have a significantly higher risk of developing MACE. Soluble suppression of tumorigenicity 2 (sST2) is a cardiac biomarker, that does not vary with age, gender, and kidney function. This study aimed to compare arterial stiffness, fluid status, and sST2 levels, between patients with PD and those with in-center HD.

METHODS

This was a cross-sectional study, which was conducted with 36 PD patients, 36 HD patients, and 36 age, and gender-matched healthy controls. We used noninvasive methods for the assessment of arterial stiffness and fluid status.

RESULTS

The patients with PD overhydrated compared to HD patients and healthy control (p < 0.001, and p = 0.05, respectively). Patients with PD had higher central systolic blood pressure and central pulse pressure than patients with HD and the control group (p = 0.004, and p = 0.01; p < 0.001, and p = 0.004, respectively). HD patients had a significantly higher level of plasma sST2 level compared to PD patients and the control group (p = 0.03, and p = 0.005). HD as maintenance dialysis modality and dialysis vintage was associated with higher plasma sST2 concentration, and having a residual renal function in dialysis patients was related to the lower plasma sST2 concentration.

CONCLUSION

PD is associated with better sST2 levels even though higher volume load than HD. In addition, the loss of RRF may be the most important factor related to increased sST2.

Prevalence of Apparent Treatment-Resistant Hypertension in ESKD Patients Receiving Peritoneal Dialysis

BACKGROUND

Apparent treatment-resistant hypertension (aTRH) is defined as failure to achieve adequate blood pressure (BP) control despite taking ≥3 antihypertensive medications from different categories or when taking ≥4 antihypertensives regardless of BP levels.

METHODS

In this cross-sectional study, we estimated the prevalence of aTRH in 140 patients receiving long-term peritoneal dialysis (PD) in four centers of Northern Greece, using the "gold-standard" method of ambulatory BP monitoring for the assessment of BP control status. The presence of subclinical overhydration was evaluated with the method of bioimpedance spectroscopy (BIS).

RESULTS

Incorporating the diagnostic threshold of 130/80 mmHg for 24-hour ambulatory BP, the prevalence of aTRH in the overall study population was 30%. Compared to patients without aTRH, those with aTRH tended to be older in age, had higher PD vintage, had higher dialysate-to-plasma creatinine ratio, had more commonly history of diabetes mellitus, and were more commonly current smokers. With respect to the volume status, the overhydration index in BIS was higher in those with versus without aTRH (2.0 ± 1.9 L vs. 1.1 ± 2.0 L, P < 0.05). The prevalence of volume overload, defined as an overhydration index in BIS > 2.5 L, was also higher in the subgroup of patients with aTRH (38.1% vs. 18.4, P = 0.01).

CONCLUSION

The present study showed that among patients on PD, the prevalence of aTRH was 30%. However, 38% of PD patients with aTRH had subclinical overhydration in BIS, suggesting that the achievement of adequate volume control may be a therapeutic opportunity to improve the management of hypertension in this high-risk patient population.The present study showed that among patients on PD, the prevalence of aTRH was 30%. However, 38% of PD patients with aTRH had subclinical overhydration in BIS, suggesting that the achievement of adequate volume control may be a therapeutic opportunity to improve the management of hypertension in this high-risk patient population.

CLINICAL TRIALS REGISTRATION

Trial Number NCT03607747.

Insight on Efficacy of Renal Artery Denervation for Refractory Hypertension with Chronic Kidney Diseases: A Long-Term Follow-Up of 24-Hour Ambulatory Blood Pressure

Aims

To explore the long-term efficacy and safety of renal denervation in patients with RHT and CKD, a post hoc analysis of eGFR subgroups was completed.

Methods

Fifty-four patients with refractory hypertension with chronic kidney disease were treated with RDN and enrolled in the study. Patients were divided into three groups according to eGFR: eGFR 46–90 ml/min group, eGFR 15–45 ml/min group, and eGFR <15 ml/min group. The planned follow-up period was 48 months to assess 24 h ambulatory blood pressure, renal function, type of antihypertensive medication, and RDN complications.

Results

The ablation sites of the GFR 46–90 ml/min group and GFR 15–45 ml/min group were 32.57 ± 2.99 and 29.53 ± 5.47, respectively. No complications occurred in the GFR 46–90 ml/min group. The GFR<15 ml/min group was treated with 27.07 ± 5.59  ablation. Renal artery dissection occurred in each group of GFR 15–45 ml/min and GFR <15 ml/min. And renal stent implantation artery was performed on these two patients. No severe renal artery stenosis occurred. There were no significant differences in Scr and eGFR between the three groups at each follow-up point. Compared with baseline, SBP was significantly of each group decreased to varying degrees at each follow-up time point. SBP decreased most in the GFR 46–90 ml/min group. Compared with baseline, the type of antihypertensive drugs used in the GFR46-90 ml/min group decreased significantly except for 36 and 48 months. At 48 months' postadmission, there was a significant decrease in the type of antihypertensive medication used in the GFR15-45 ml/min group, and there was no significant decrease in the type of antihypertensive medication used in the GFR<15 ml/min group.

Conclusions

RDN can safely reduce SBP in CKD patients combined with RHT for 48 months, with the most pronounced reduction in the GFR15-45 ml/min group. The variety of antihypertensive drugs was significantly reduced after RDN. This was particularly evident in patients with GFR 15–45 ml/min.

Multifrequency bioimpedance by spectroscopy vs. routine methods in the management of hydration status in peritoneal dialysis patients: A randomized control trial

Background

Overhydration (OH) is common in peritoneal dialysis (PD) and increases the cardiovascular risk. Multifrequency bioimpedance spectroscopy (BIS) has been proposed to estimate the hydration in dialysis. Our objective was to evaluate if BIS is superior than control based on clinical assessment plus single-frequency bioimpedance (SF-BIA) on the fluid control and intermediate cardiovascular outcomes.

Methods

Randomized controlled study in adult PD patients, with a 9-month follow-up, allocated into two groups: control and BIS. Data were collected from medical records. SF-BIA and BIS, laboratory exams, ambulatory blood pressure monitoring, echocardiography (ECHO), and pulse wave velocity (PWV) were evaluated. The BIS data were available to the medical team only in BIS group.

Results

34 patients completed the study, 17 in each group. At the endpoint the BIS group had a significant (p < 0.05) greater proportion of patients with OH/extracellular water (OH/ECW%) ≤ 15% than the control (94.1% vs. 52.9%), and a lower OH mean (2.1 ± 1.6 vs. 0.9 ± 1.1 L). The control group has a significant increase in the tumor necrosis factor alpha median concentration from baseline to six [11.9 (6.0–24.1) vs. 44.7 (9.4–70.6) pg/ml] and 9 months [11.9 (6.0–24.1) vs. 39.4 (27.9–62.6) pg/ml], and in the N-terminal fragment of pro-B-type natriuretic peptide median [239 (171.5–360.5) vs. 356 (219–1,555) pg/ml]. For cardiovascular parameters, BIS group presented a significant reduction in radial PWV [7.7 (6.9–9.2) vs. 6.5 (5.5–8.4) m/s] at 9 month, while in the control presented a significant increase in mean central systolic blood pressure (BP) (106.8 ± 11.2 vs. 117.6 ± 16.5 mmHg) and in central diastolic BP (90.4 ± 9.8 vs. 103.3 ± 12.5 mmHg) at 9 months. The left ventricular mass (LVM)/body surface presented a significant reduction in the control (109.6 ± 30.8 vs. 101.2 ± 28.9 g/m²) and BIS group (107.7 ± 24.9 vs. 96.1 ± 27.0 g/m²) at 9 months.

Conclusion

The results suggest BIS is superior than the clinical evaluation plus SF-BIA for the fluid control of PD patients.

Clinical trial registration

[https://www.ClinicalTrials.gov], identifier [RBR-10k8j3bx].

Sacubitril-Valsartan Increases Ultrafiltration in Patients Undergoing Peritoneal Dialysis: A Short-Term Retrospective Self-Controlled Study

Aim

There are few data about the effectiveness and safety of angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril-valsartan in end-stage renal disease (ESRD) patients undergoing peritoneal dialysis (PD). The present study was conducted to evaluate the association between sacubitril-valsartan treatment and peritoneal ultrafiltration (PUF) in PD patients.

Methods and Results

Forty-seven ESRD patients undergoing PD for at least 3 months without severe congestive heart failure (CHF) were included in this study. Sacubitril-valsartan (generally 100 mg b.i.d) was administered after consultation with the nephrologist. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) were required to be discontinued 36 h before prescribing sacubitril-valsartan. Other treatments and dialysis modality did not change. Baseline demographic and clinical parameters were collected before ARNI administration, and daily PUF, urine volume, total output, blood pressure (BP), and body weight were collected within 7 days before and after ARNI treatment. After treated with sacubitril-valsartan, 30 patients (63.8%) had a significant increase of PUF [up to 150.4 (110.7, 232.1) ml per day], while the remaining 17 (36.2%) had a slight decrease. The overall increase of PUF was 66.4 (21.4, 123.2) ml/24 h within the 7 days after sacubitril-valsartan administration, which was significantly higher than those before (P = 0.004). Total output, BP, and body weight also significantly improved. No adverse drug reactions were observed.

Conclusions

Our study indicated that sacubitril-valsartan was associated with the increase of short-term PUF and total output in PD patients.

Current apparent treatment-resistant hypertension in patients undergoing peritoneal dialysis: A multi-center cross-sectional study

Apparent treatment‐resistant hypertension (aTRH) is the most commonly used term to report resistant hypertension (RH) and is considered as a common problem in dialysis population. However, few reports have focused on peritoneal dialysis (PD) hypertensive patients. The authors conducted a multi‐center cross‐sectional study involving 1789 PD patients from nine centers in Guangdong, China. The prevalence of aTRH was estimated by home blood pressure (BP) monitoring. Evaluating drug adherence through Eight‐item Morisky Medication Adherence Scale (MMAS‐8) and pill counting was performed to assess RH in one PD center. Related factors of aTRH were analyzed using logistic regression analysis. The prevalence of aTRH in PD patients was estimated at 42.2% (755 out of 1789 hypertensive patients) based on home BP. Of those, 91.4% patients were classified as uncontrolled RH, 2.0% as controlled RH, and 6.6% as refractory hypertension. The prevalence of RH was 40.6% and 41.9% among those with medium/high adherence based on the MMAS‐8 scores and the pill counting rate, respectively. PD patients who were younger, with higher body mass index, with lower serum albumin and poorer dialysis adequacy were significantly associated with higher aTRH incident. In conclusion, the present study demonstrates a high prevalence of aTRH in PD population, which occurs in about two in five treated hypertensive patients. Nutritional status and dialysis adequacy might tightly associate with aTRH.

Coexistence of diabetes mellitus and pre-existing cardiovascular disease and mortality in Chinese patients on peritoneal dialysis

Background

Little is known about the association between the coexistence of diabetes mellitus (DM) and pre-existing cardiovascular disease (CVD) and mortality in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

Methods

A retrospective cohort study of 2939 Chinese incident CAPD patients was conducted between January 1, 2005, and December 31, 2018. The primary and secondary outcomes were all-cause and CVD mortality. The association between the coexistence of DM and pre-existing CVD and mortality was evaluated using Cox proportional hazards regression.

Results

Over a median of 35.1 months of follow-up, 519 patients (17.7%) died, with 258 (8.8%) being CVD-related deaths. DM plus pre-existing CVD, DM, and pre-existing CVD were associated with a higher risk of all-cause mortality (adjusted hazard ratio [HR], 2.85; 95% confidence interval [CI], 2.18 to 3.72; adjusted HR, 1.89; 95% CI, 1.50 to 2.38; and HR, 1.43; 95% CI, 1.07 to 1.92; P for tend < 0.001) and CVD mortality (adjusted HR, 2.79; 95% CI, 1.91 to 4.08; HR, 1.88; 95% CI, 1.35 to 2.61; and HR, 1.82; 95% CI, 1.23 to 2.68; P for trend < 0.001) than no DM or pre-existing CVD. Subgroup analyses stratified by sex, hypertension status, and hyperlipidemia status showed a similar pattern.

Conclusions

The coexistence of DM and pre-existing CVD at the start of CAPD was more strongly associated with a higher risk of all-cause and CVD mortality than DM or pre-existing CVD alone.

Epidemiology of Hypertension among Patients on Peritoneal Dialysis Using Standardized Office and Ambulatory Blood Pressure Recordings

INTRODUCTION

Prior studies conducted in peritoneal dialysis (PD) patients in the late 1990s provided considerably variable estimates of the prevalence and control of hypertension. The present study aimed to investigate the current state of hypertension management in this high-risk population.

METHODS

In 140 stable PD patients, we performed standardized automated office blood pressure (BP) measurements and 24-h ambulatory BP monitoring (ABPM) using the Mobil-O-Graph device (IEM, Germany). Office and ambulatory hypertension was diagnosed in patients with office BP ≥140/90 mm Hg and 24-h BP ≥130/80 mm Hg, respectively. Patients treated with ≥1 BP-lowering medications were also classified as hypertensives.

RESULTS

The prevalence of office and ambulatory hypertension was 92.9% and 95%, respectively. In all, 92.1% of patients were being treated with an average of 2.4 BP-lowering medications daily. Adequate BP control was achieved in 52.3% and 38.3% of hypertensives by office BP and ABPM, respectively. The agreement between these 2 techniques in the identification of patients with BP levels above the diagnostic thresholds of hypertension was moderate (k-statistic: 0.524). In all, 5% of patients were normotensives with both techniques, 31.4% had controlled hypertension, 5% had white-coat hypertension, 19.3% had masked hypertension, and 39.3% had sustained hypertension. Isolated nocturnal hypertension was detected in 23.6% of patients, whereas no patient had isolated daytime hypertension.

CONCLUSION

Among PD patients, hypertension is highly prevalent and remains often inadequately controlled. The use of ABPM enables the better classification of severity of hypertension and identification of isolated nocturnal hypertension, which is a common BP phenotype in the PD population.

Polypharmacy Predicts Onset and Transition of Frailty, Malnutrition, and Adverse Outcomes in Peritoneal Dialysis Patient

BACKGROUND

Polypharmacy, frailty and malnutrition are known predictors of adverse outcomes in dialysis patients. Little has reported about their interaction and composite prognostic values. We aimed to describe the interaction between polypharmacy, frailty, nutrition, hospitalization, and survival in peritoneal dialysis patients.

METHODS

In this prospective cohort study, we recruited 573 peritoneal dialysis patients. Drug burden was measured by medication number and daily pill load. Frailty and nutrition were assessed by the validated Frailty Score (FQ) and Subjective Global Assessment (SGA) respectively. All patients were followed for two years. Primary outcome was all-cause mortality. Secondary outcomes were fall and fracture episodes, hospitalization, change in FQ and SGA.

RESULTS

At baseline, each patient took 7.5 ± 2.6 medications with 15.5 ± 8.5 tablets per day. Medication number, but not daily pill load predicted baseline FQ (p = 0.004) and SGA (p = 0.03). Over 2 years, there were 69 fall and 1,606 hospitalization episodes. In addition, 148 (25.8%) patients died, while FQ and SGA changed by 0.73 ± 4.23 and -0.07 ± 1.06 respectively in survivors. Medication number (hospitalization: p = 0.02, survival: p = 0.005), FQ (hospitalization: p < 0.001; survival: p = 0.01) predicted hospitalization and survival. Medication number also predicted fall episodes (p = 0.02) and frailty progression (p = 0.002). Daily pill load did not predict any of these outcomes.

CONCLUSIONS

Drug burden is high in peritoneal dialysis patients, and it carries important prognostic implication. Medication number but not pill load significantly predicted onset and progression of frailty, malnutrition, fall, hospitalization, and mortality.

The utility of remote patient management in peritoneal dialysis

Remote patient management (RPM) programs are one of the most crucial innovations in the peritoneal dialysis (PD) field that have been developed in the last decade. RPM programs are associated with favourable clinical outcomes by increasing the adherence of the patients to PD prescription. The literature supports that RPM is associated with increased blood pressure control and technique survival, and decreased hospitalization rate, length of hospital stay and health costs. RPM programs also facilitate patient follow-up during the coronavirus disease 2019 pandemic, increase treatment adherence and lead to better clinical outcomes. However, published data remain scarce and mainly consist of observational or retrospective studies with relatively low numbers of patients. Therefore, randomized controlled trial results will be more informative to demonstrate the effect of RPM programs on clinical outcomes.

Évaluation de la performance de la mesure conventionnelle et séquentielle de la pression artérielle en centre chez les patients en dialyse péritonéale à Dakar

Introduction : L’objectif de cette étude était d’évaluer les performances des mesures conventionnelles (MCPA) et séquentielles (MSPA) de la pression artérielle en prenant la MAPA comme référence. Patients et méthodes : A travers une étude transversale incluant 17 patients suivis dans l’unité de DP de l’Hôpital Aristide Le Dantec, la PA a été mesurée par 3 méthodes : i) une mesure automatisée (OMRON M3 COMFORT) effectué par un personnel de santé dite MCPA (OMRON M3 COMFORTTM) ; ii) la moyenne de 5 mesures automatisées chez un patient isolé dans un box dite MSPA ; iii) la MAPA des 24h avec l’appareil CONTECTM (Germany). L’HTA a été retenue devant une PA supérieure à 130/80 mmHg à la MAPA des 24h. Résultats : L’aire sous la courbe (AUC) de la PAS était similaire (p=0,28) entre la MSPA [AUC, 0,933 ; IC à 95 %, 0,813 – 1,000] et la MCPA [AUC, 0,900 ; IC à 95 %, 0,752 – 1,000]. Concernant la PAD, la MSPA [AUC, 0,858 ; IC à 95 %, 0,638 – 1,000] était similaire (p=1) à la MCPA [AUC, 0,917 ; IC à 95 %, 0,753 – 1,000]. À l’analyse de Bland-Altman, la MCPA surestimait  la PAS de 11,65 mmHg et la PAD de 3,94 mmHg. La MSPA quant à elle surestimait la PAS de 6,2 mmHg et la PAD de 4,35 mmHg. Conclusion : La MSPA et la MCPA sont performantes dans le diagnostic de l’HTA ambulatoire chez les patients en dialyse péritonéale à Dakar.

The associations of blood pressure parameters with all-cause and cardiovascular mortality in peritoneal dialysis patients: a cohort study in China

BACKGROUND

It remains controversial to claim blood pressure (BP) as a leading risk factor for high risk of death in peritoneal dialysis patients, and less is known about the relationship between BP and mortality in Chinese peritoneal dialysis patients.

METHODS

From Zhejiang Renal Data System in China, we collected data on patients treated and followed up at 98 peritoneal dialysis centres from 2008 to 2016. The associations of BP parameters [SBP, DBP, mean arterial pressure (MAP) and pulse pressure (PP)] with all-cause and cardiovascular mortality were examined. We fitted Cox models for mortality with penalized splines using nonparametric smoothers. Several sensitivity analyses were performed to confirm the robustness of our primary findings.

RESULTS

A total of 7335 Chinese peritoneal dialysis patients were included. During a median follow-up of 35.8 months, 1281 (17.5%) patients died. SBP, DBP, MAP follow a U-shaped pattern of both all-cause and cardiovascular mortality. PP presents a reverse L-shaped association with all-cause mortality. Either a higher (SBP >141, DBP >85 or MAP >102 mmHg) or lower (SBP <119, DBP <67 or MAP <88 mmHg) BP tends to have a significantly higher all-cause and cardiovascular mortality risk. Higher PP (>60 mmHg) is related to a higher risk of all-cause mortality, but not cardiovascular mortality. These associations remain the same in our competing risk analysis and subgroup analyses.

CONCLUSION

These data indicate U-shaped associations of SBP, DBP and MAP with all-cause mortality and cardiovascular mortality, respectively, and a reverse L-shaped association of PP with all-cause mortality. Further studies are needed to reliably establish the optimal BP targets for better hypertension control in peritoneal dialysis patients.

MMP-7 affects peritoneal ultrafiltration associated with elevated aquaporin-1 expression via MAPK/ERK pathway in peritoneal mesothelial cells

Peritoneal membrane dysfunction and the resulting ultrafiltration failure are the major disadvantages of long-term peritoneal dialysis (PD). It becomes increasingly clear that mesothelial cells play a vital role in the pathophysiological changes of the peritoneal membrane. Matrix metalloproteinases (MMPs) function in the extracellular environment of cells and mediate extracellular matrix turnover during peritoneal membrane homeostasis. We showed here that dialysate MMP-7 levels markedly increased in the patients with PD, and the elevated MMP-7 level was negatively associated with peritoneal ultrafiltration volume. Interestingly, MMP-7 could regulate the cell osmotic pressure and volume of human peritoneal mesothelial cells. Moreover, we provided the evidence that MMP-7 activated mitogen-activated protein kinases (MAPKs)-extracellular signal-regulated kinase 1/2 (ERK) pathway and subsequently promoted the expression of aquaporin-1 (AQP-1) resulting in the change of cell osmotic pressure. Using a specific inhibitor of ERK pathway abrogated the MMP-7-mediating AQP-1 up-regulation and cellular homeostasis. In summary, all the findings indicate that MMP-7 could modulate the activity of peritoneal cavity during PD, and dialysate MMP-7 might be a non-invasive biomarker and an alternative therapeutic target for PD patients with ultrafiltration failure.

The Relation of Clinic and Ambulatory BP with the Risk of Cardiovascular Events and All-Cause Mortality among Patients on Peritoneal Dialysis

Large observational studies showed a U-shaped association of clinic blood pressure (BP) with mortality among patients undergoing peritoneal dialysis (PD). Whether ambulatory BP provides a more direct risk signal in this population remains unknown. In a prospective cohort of 108 PD patients, standardized clinic BP was recorded at baseline with the validated device HEM-705 (Omron, Healthcare, Bannockburn, IL, USA) and 24-h ambulatory BP monitoring was performed using the Mobil-O-Graph monitor (IEM, Stolberg, Germany). Over a median follow-up of 16 months (interquartile range: 19 months), 47.2% of the overall population reached the composite outcome of non-fatal myocardial infarction, non-fatal stroke, or all-cause death. In Cox-regression analysis, systolic but not diastolic BP was prognostically informative. Compared with the reference quartile 1 of 24-h systolic BP (SBP), the multivariate-adjusted hazard ratio for the composite outcome was 1.098 (95% confidence interval (CI): 0.434–2.777) in quartile 2, 1.004 (95% CI: 0.382–2.235) in quartile 3 and 2.449 (95% CI: 1.156–5.190) in quartile 4. In contrast, no such association was observed between increasing quartiles of clinic SBP and composite outcome. The present study shows that among PD patients, increasing ambulatory SBP is independently associated with higher risk of adverse cardiovascular events and mortality, providing superior prognostic information than standardized clinic SBP.

Serum Sodium Modifies the Association of Systolic Blood Pressure with Mortality in Peritoneal Dialysis Patients

INTRODUCTION

High serum sodium is associated with increased blood pressure (BP) in dialysis patients, which is a risk factor for cardiovascular (CV) disease. However, the interaction between serum sodium and BP and their association with clinical outcomes in peritoneal dialysis (PD) patients is uncertain.

METHODS

We analyzed a retrospective cohort of 1,656 incident PD patients from January 2006 to December 2013, who were followed up until December 2018. Cox proportional hazards regression models were used to evaluate the association of serum sodium and BP with all-cause and CV mortality. A priori interaction between serum sodium and systolic BP (SBP) was explored, and a subgroup analysis was performed by stratifying SBP into the following 3 groups: <110, 110-130, and >130 mm Hg.

RESULTS

Mean baseline serum sodium was 140.2 ± 3.6 mmol/L, mean SBP was 137 ± 20 mm Hg, and diastolic BP was 85 ± 14 mm Hg. During a median (range) follow-up time of 46.5 (2.6-154.3) months, 507 patients died, 252 of whom died due to CV disease. SBP did not predict all-cause and CV mortality when BP was assessed as a continuous variable. However, SBP >130 or <110 mm Hg was associated with higher risk of all-cause and CV mortality compared with SBP of 110-130 mm Hg. There was a significant interaction between baseline serum sodium and SBP for all-cause mortality (p for interaction = 0.016). In subgroup analysis, among those with SBP >130 mm Hg, the risk of all-cause mortality was elevated in those with serum sodium ≥140 mmol/L (adjusted hazard ratio [aHR] 1.45 [95% confidence interval (CI): 1.07-1.98]), but not for those with serum sodium <140 mmol/L (aHR 1.27 [95% CI: 0.89-1.82]). Conversely, among those with SBP <110 mm Hg, those with serum sodium <140 mmol/L had an elevated risk of mortality (aHR 1.99 [95% CI: 1.31-3.02]), but not those with serum sodium ≥140 mmol/L (aHR 1.15 [95% CI: 0.74-1.79]) (p for interaction = 0.028).

CONCLUSION

The association of BP with mortality was modified by serum sodium levels in PD patients. Further studies are needed to evaluate whether individualized BP control based on serum sodium levels contributes to improve patient outcomes.

Effect of remote patient management in peritoneal dialysis on haemodynamic and volume control

AIM

Reduced treatment compliance in patients with peritoneal dialysis facilitates the development of fluid overload and as a result increased blood pressure and vascular stiffness in the long term. We aimed to evaluate blood pressure change and anti-hypertensive needs of patients within 1 year after the changeover to remote monitoring automated peritoneal dialysis (RM-APD) and compare the effect of RM-APD and continuous ambulatory peritoneal dialysis (CAPD) on peripheral and central haemodynamic parameters, volume status of patients and anti-hypertensive drug needs.

METHODS

This was an observational and cross-sectional study. We enrolled 15 patients performing CAPD, 20 patients performing RM-APD, and 38 age, and gender-matched healthy control. We measured pulse wave velocity to assess arterial stiffness, peripheral and central haemodynamic parameters. We measured the volume status of participants via bioimpedance spectroscopy.

RESULTS

The mean excess hydration of patients who underwent CAPD were higher than those who performed RM-APD and healthy control (P = .02). We found that mean diastolic blood pressure, heart rate, central systolic and diastolic blood pressure, and central pulse pressure were significantly different between the RM-APD, CAPD and healthy control (P = .02, P = .05, P = .007, P = .05 and P = .005, respectively). Post hoc analysis of these results showed that the differences between the groups were caused by the healthy control group and the patients with underwent CAPD. Daily anti-hypertensive drug count in patients with performing RM-APD was reduced over time (P < .001).

CONCLUSION

The RM-APD provides better control of peripheral blood pressure and decrease of central haemodynamic parameters via controlling the excess body water.

Uncertainties in BP management in dialysis patients

Hypertension in dialysis patients is extremely common. In this article, we review the current evidence for blood pressure (BP) goals in hemodialysis patients, and consider the effectiveness of interventions by which BP may be lowered, including manipulation of dietary and dialysate sodium; optimization of extracellular water; prolongation of dialysis time; and antihypertensive medication. Although two meta-analyses suggest lowering BP using antihypertensive drugs might be beneficial in reducing cardiovascular events and mortality, there are insufficient rigorously designed trials in hypertensive hemodialysis populations to determine preferred antihypertensive drug classes. We suggest aiming for predialysis systolic BP between 130 and 159 mm Hg, while at the same time acknowledge the significant limitations of the data upon which it is based. We conclude by summarizing current knowledge as regards management of hypertension in the peritoneal dialysis population and make recommendations for future research in this field.

Automated Remote Monitoring for Peritoneal Dialysis and Its Impact on Blood Pressure

Introduction: Peritoneal dialysis (PD) provides a safe, home-based continuous renal replacement therapy for patients. The adherence of the patients to the prescribed dialysis fluids cannot always be monitored by physicians. Remote monitoring automated peritoneal dialysis (RM-APD) can affect patients’ compliance with treatment and, thus, clinical outcomes. Objective: We aimed to evaluate the clinical outcomes of patients with a remote access program. Methods: This was an observational study. We analyzed the effect of RM-APD on treatment adherence, dialysis adequacy, and change in blood pressure control, sleep quality, and health-related quality of life during the 6 months of follow-up. Results: A total of 15 patients were enrolled in this study. It was found that there was a significant decrease (99 ± 19 vs. 89 ± 11 mm Hg) in mean arterial blood pressure of patients, and a considerable increase in Kt/V was observed in the sixth month after the RM-APD switch (2.11 ± 0.4 vs. 2.25 ± 0.5). A significant increase was found when comparing the 3-month and 6-month ultrafiltration amounts before RM-APD and the ultrafiltration amount within 6 months after RM-APD (800 mL [500–1,000] and 752 mL [490–986] vs. 824 mL [537–1,183]). The daily antihypertensive pill need (4 [0–7] vs. 2 [0–6]) and alarms received from the device decreased (from 4 [3–8] to 2 [0–3]) at the sixth month of the switch. There was no significant change in sleep quality and health-related quality of life within 6 months. Conclusion: This study showed that treatment adherence and ultrafiltration amounts of patients increased with the use of RM-APD, as well as better blood pressure control with fewer antihypertensive drugs.

Sodium toxicity in peritoneal dialysis: mechanisms and "solutions"

The major trials in peritoneal dialysis (PD) have demonstrated that increasing peritoneal clearance of small solutes is not associated with any advantage on survival, whereas sodium and fluid overload heralds higher risk of death and technique failure. On the other hand, higher sodium and fluid overload due to loss of residual kidney function (RKF) and higher transport membrane is associated with poor patient and technique survival. Recent experimental studies also show that, independently from fluid overload, sodium accumulation in the peritoneal interstitium exerts direct inflammatory and angiogenetic stimuli, with consequent structural and functional changes of peritoneum, while in patients with Chronic Kidney Disease sodium stored in interstitial skin acts as independent determinant of left ventricular hypertrophy. Noteworthy, this tissue pool of sodium is modifiable being removed by dialysis. Therefore, novel PD strategies to optimize sodium removal, including the use of bimodal and/or low-sodium solutions, are actively tested. Nonetheless, a holistic approach aimed at preserving peritoneal function and the kidney may represent the key of therapy success in the hard task of preserving adequate sodium balance in PD patients. In this review, we describe the available evidence on sodium toxicity in PD, either related or unrelated to fluid overload, and we also discuss about possible "solutions" to preserve or restore sodium balance in PD patients.

[Associations of mean arterial pressure levels with mortality in patients with peritoneal dialysis]

OBJECTIVE

To investigate the associations between mean arterial pressure (MAP) and mortality in patients with peritoneal dialysis (PD).

METHODS

A total of 1737 patients with terminal renal diseases under PD in the First Affiliated Hospital of Zhejiang University from 2008 to 2016 were enrolled. Patients were followed up for 33.0(19.3, 52.4) months. The mean arterial pressure over the first 3 months of PD therapy were calculated. All-cause death and cardiovascular death were assessed using Cox regression models adjusted for demographics, laboratory measurements, comorbid conditions and antihypertensive medications.

RESULTS

During the follow-up, 208 patients died, among which 95(45.7%) patients died of cardiovascular causes. Compared with patients with MAP >95-<120 mmHg, patients with MAP ≤ 95 mmHg were associated with significantly higher risk of all-cause death (HR=1.40,95%CI:1.01-1.93,P<0.05); patients with MAP ≥ 120 mmHg were associated with significantly higher risk of all-cause (HR=2.12,95%CI:1.32-3.40, P<0.01) and cardiovascular morality (HR=2.55, 95%CI:1.38-4.70, P<0.01). MAP presents a U-shaped association with all-cause mortality and a J-shaped association with cardiovascular mortality.

CONCLUSIONS

Both high MAP and low MAP are associated with higher risk of mortality in PD patients.