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Blunted nocturnal blood pressure decrease and left-ventricular mass in hypertensive hemodialysis patients
Riccardo M Fagugli1, Giuseppe Quintaliani, Paolo Pasini
1Nephrology-Dialysis, Silvestrini Hospital, Perugia, Italy. rmfag@tin.it
Insights
In hypertensive hemodialysis patients, most are non-dippers, but this classification doesn't significantly impact blood pressure or left ventricular mass. Volume overload is the primary driver of left ventricular hypertrophy in this population.
Area of Science:
- Nephrology
- Cardiology
- Hypertension Research
Background:
- Left-ventricular hypertrophy (LVH) is a common complication in hemodialysis (HD) patients.
- Hypertension is a major risk factor for cardiac morbidity in HD patients, with many exhibiting a blunted nocturnal blood pressure (BP) decrease (non-dippers).
- Previous studies in essential hypertensives suggest non-dippers have higher cardiac events and left ventricle (LV) mass, but results are conflicting in dialysis patients.
Purpose of the Study:
- To investigate differences in LV mass between dipper and non-dipper hypertensive HD patients.
- To assess the relationship between BP patterns, LV mass, and extracellular water distribution in HD patients.
Main Methods:
- 24-hour ambulatory BP monitoring was conducted on HD and inter-HD days for 66 hypertensive HD patients.
- Patients were classified as dippers (≥10% nocturnal systolic BP decrease) or non-dippers.
- Echocardiography and bioimpedance were used to assess LV mass index (LVMi) and extracellular water (ECW) distribution.
Main Results:
- 71% of patients were classified as non-dippers.
- No significant differences in 48-hour systolic and diastolic BP or LVMi were observed between dipper and non-dipper groups.
- A strong correlation was found between ECW percentage and LVMi (r = 0.53, p < 0.001), while BP parameters did not correlate with LVMi.
Conclusions:
- The non-dipper status in hypertensive HD patients is not associated with significantly different 48-hour BP or LV mass compared to dippers.
- Volume overload, indicated by ECW, appears to be the primary independent determinant of LVH in this patient cohort.
- Clinical management should focus on volume status to address LVH in hypertensive HD patients.
Abstract:
Left-ventricular hypertrophy (LVH) represents a frequent complication in hemodialysis (HD) patients. Hypertension is a well-known risk factor of cardiac morbidity which is present in 2 of 3 patients: among them about 60% have a blunted nocturnal decrease of blood pressure (BP). Although some large studies on essential hypertensives have documented that non-dipper patients have a higher number of cardiac events and a higher left ventricle (LV) mass than dipper ones, conflicting results have been reported for dialysis patients. Therefore, the aim of our study was to assess differences in LV mass between dipper and non-dipper hypertensive HD patients. We studied 66 patients with 24-hour ambulatory BP monitoring performed on HD and on inter-HD day. They were classified as dipper when a decrease of at least 10% of nocturnal systolic blood pressure on the inter-HD day was present. Echocardiography and bioimpedance were performed. 29% of the patients were classified as dippers and 71% as non-dippers. The 48-hour systolic and diastolic BP were not significantly different between the two groups (SBP: dipper = 144 +/- 12.9 mm Hg, non-dipper = 149 +/- 17.8 mm Hg; DBP: dipper = 80 +/- 9.9 mm Hg, non-dipper = 81 +/- 10.6 mm Hg). LV mass index (LVMi) did not differ between the two groups (dipper = 143.1 +/- 40.7 g/m(2); non-dipper = 159.4 +/- 46.3 g/m(2)). No differences were reported between dipper and non-dipper patients regarding extracellular water distribution (ECW: 48.1 +/- 7.7 vs. 49.8 +/- 10.8%). SBP night/day ratio and 48-hour SBP were not correlated to LVMi. A strong correlation was reported between ECW% and LVMi (r = 0.53, p < 0.001). In conclusion, 2 of 3 hypertensive HD patients are non-dipper, and this condition does not seem to be associated with significant differences in 48-hour blood pressure and LV mass. Volume overload appears to be the main independent determinant of LVH in these patients.