Ambulatory recording of wave reflections and arterial stiffness during intra- and interdialytic periods in patients treated with dialysis

Abstract

Background and objectives: Wave reflections and arterial stiffness are independent cardiovascular risk factors in ESRD. Previous studies in this population included only static recordings before and after dialysis. This study investigated the variation of these indices during intra- and interdialytic intervals and examined demographic, clinical, and hemodynamic variables related to arterial function in patients undergoing hemodialysis.

Design, setting, participants, & measurements: Between February 2013 and May 2014, a total of 153 patients receiving maintenance hemodialysis in five dialysis centers of northern Greece underwent ambulatory BP monitoring with the newly introduced Mobil-O-Graph device (IEM, Stolberg, Germany) over a midweek dialysis session and the subsequent interdialytic period. Mobil-O-Graph is an oscillometric device that records brachial BP and pulse waves and estimates, via generalized transfer function, aortic BP, augmentation index (AIx) as a measure of wave reflections, and pulse wave velocity (PWV) as an index of arterial stiffness.

Results: AIx was lower during dialysis than in the interdialytic period of dialysis-on day (Day 1) (mean±SD, 24.7%±9.7% versus 26.8%±9.4%; P<0.001). In contrast, PWV remained unchanged between these intervals (9.31±2.2 versus 9.29±2.3 m/sec; P=0.60). Both AIx and PWV increased during dialysis-off day (Day 2) versus the out-of-dialysis period of Day 1 (28.8%±9.8% versus 26.8%±9.4% [P<0.001] and 9.39±2.3 versus 9.29±2.3 m/sec [P<0.001]). Older age (odds ratio [OR], 1.09; 95% confidence interval [95% CI], 1.02 to 1.15), female sex (OR, 7.56; 95% CI, 1.64 to 34.81), diabetic status (OR, 8.84; 95% CI, 1.76 to 17.48), and higher mean BP (OR, 1.17; 95% CI, 1.09 to 1.27) were associated with higher odds of high AIx; higher heart rate was associated with lower odds (OR, 0.71; 95% CI, 0.63 to 0.80) of high AIx. Older age (OR, 2.04; 95% CI, 1.61 to 2.58) and higher mean BP (OR, 1.15; 95% CI, 1.05 to 1.27) were independent correlates of high PWV.

Conclusions: This study showed a gradual interdialytic increase in AIx, whereas PWV was only slightly elevated during Day 2. Future studies are needed to elucidate the value of these ambulatory measures for cardiovascular risk prediction in ESRD.

Keywords: Mobil-O-Graph; PWV; hemodialysis; interdialytic period; wave reflections.

Figure 1.

Overlap of forward and backward traveling of pulse waves in the ascending aorta. Under physiologic conditions (i.e., in young individuals with elastic central arteries) the reflected pulse wave returns to the ascending aorta during diastole of the subsequent cardiac cycle. In patients with stiff central arteries (i.e., in the elderly or in patients with ESRD) the higher pulse wave velocity results in premature arrival of the backward-traveling pulse wave (during systole rather diastole), leading to augmentation of aortic systolic and pulse pressure. Vertical lines in the figure represent the end of the systolic phase of cardiac cycle.

Figure 2.

Variation in mean blood pressure, wave reflection and arterial stiffness indices during intra- and interdialytic periods of the 48-hour ambulatory recording for patients in the morning dialysis shift (n=85). Variation in mean BP (MBP) (A); variation in augmentation index (AIx) and in heart rate-adjusted AIx (AIx75) (B) and (C); variation in pulse wave velocity (PWV) (D). Gray shading indicates the in-dialysis period; out-of-dialysis periods of Day 1 and Day 2 are separated by dotted vertical lines.