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. 2010 Nov;21(11):1970-8.
doi: 10.1681/ASN.2010010125. Epub 2010 Oct 14.

Age, race, diabetes, blood pressure, and mortality among hemodialysis patients

Orrin B Myers  1 , Christopher Adams, Mark R Rohrscheib, Karen S Servilla, Dana Miskulin, Edward J Bedrick, Philip G Zager
Affiliations

Age, race, diabetes, blood pressure, and mortality among hemodialysis patients

Orrin B Myers et al. J Am Soc Nephrol. 2010 Nov.

Abstract

Observational studies involving hemodialysis patients suggest a U-shaped relationship between BP and mortality, but the majority of these studies followed large, heterogeneous cohorts. To examine whether age, race, and diabetes status affect the association between systolic BP (SBP; predialysis) and mortality, we studied a cohort of 16,283 incident hemodialysis patients. We constructed a series of multivariate proportional hazards models, adding age and BP to the analyses as cubic polynomial splines to model potential nonlinear relationships with mortality. Overall, low SBP associated with increased mortality, and the association was more pronounced among older patients and those with diabetes. Higher SBP associated with increased mortality among younger patients, regardless of race or diabetes status. We observed a survival advantage for black patients primarily among older patients. Diabetes associated with increased mortality mainly among older patients with low BP. In conclusion, the design of randomized clinical trials to identify optimal BP targets for patients with ESRD should take age and diabetes status into consideration.

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Figures

Figure 1.
Figure 1.
Analysis of the combined association of predialysis SBP and DBP on mortality in incident HD patients reveals that mortality was greater at lower versus higher SBP. Model adjusted for age; gender; race; cause of ESRD; and time-varying serum albumin, hemoglobin, creatinine, dialysis dosage, and postdialysis weight. Referent: SBP = 140 mmHg, DBP = 80 mmHg.
Figure 2.
Figure 2.
Age interacts with BP so that (A) mortality among incident HD patients is highest for older patients with lower SBP. Only patients <40 years old have increased mortality risk with increasing SBP. (B) Mortality is highest for older patients with lower DBP. (C) Mortality risk and PP show higher mortality risk for older patients with low PP. Models adjusted for age; gender; race; cause of ESRD; and time-varying serum albumin, hemoglobin, creatinine, dialysis dosage, and postdialysis weight. Error bars are point-wise 95% CIs. Referent: SBP = 140 mmHg, DBP = 80 mmHg, PP = 73 mmHg.
Figure 3.
Figure 3.
Black incident HD patients have lower mortality risk than white patients across all SBP and DBP (A and B), and diabetic patients have increased mortality risk when SBP <140 mmHg (C and D). Models adjusted for age; gender; race; cause of ESRD; and time-varying serum albumin, hemoglobin, creatinine, dialysis dosage, and postdialysis weight. Error bars are point-wise 95% CIs. Referent: SBP = 140 mmHg, DBP = 80 mmHg.
Figure 4.
Figure 4.
A survival advantage for black versus white incident HD patients exists for patients over 40 years across all SBP but not for younger patients (A through C). Diabetic patients over age 40 with lower SBP (<140 mmHg) have increased mortality relative to nondiabetic patients (D through F). The relationships between SBP and mortality among younger diabetic versus nondiabetic patients are similar. Models adjusted for gender; race; cause of ESRD; and time-varying serum albumin, hemoglobin, creatinine, dialysis dosage, and postdialysis weight. Error bars are point-wise 95% CIs. Referent: SBP = 140 mmHg and age shown in each panel.
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