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Background Results
Pulse pressure (PP) is an independent predictor of cardiovascular There were 27 deaths; three deaths occurred after the change to
and/or all-cause mortality in patients with underlying cardiovascular hemodialysis (HD) (subjects died within 3 months after HD) and were
disease. We examined whether PP can be used to predict overall counted as events during survival analysis. The overall 30-month
mortality in peritoneal dialysis (PD) patients. survival (Kaplan–Meier curves) times were significantly different
among the tertiles of PP (P < 0.05). Increased PP was significantly
Methods associated with overall mortality regardless of adjustment for systolic
We studied 153 PD patients (mean age, 54.5 ± 14.2 years) with blood pressure (SBP) or diastolic blood pressure (DBP).
end-stage renal disease. PP was measured monthly for 3 months.
At the time of the third PP measurement, baseline demographic, Conclusions
clinical, biochemical, and dialysis data were collected. Patients PP may be the most consistent blood pressure indicator of mortality
were stratified into tertiles according to average PP, and the risk. All-cause mortality events in PD patients are more related to
relationship between blood pressure parameters and all-cause pulsatile stress caused by the stiffness of large arteries during systole
mortality over a 30-month follow-up was assessed using Cox (reflected in a rise of PP) than to steady-state stress stemming from
regression. resistance during diastole (reflected in a rise of SBP and DBP).
Am J Hypertens 2008; 21:1318-1323 © 2008 American Journal of Hypertension, Ltd.
Blood pressure is a powerful risk factor for cardiovascu- compliance.5,7 On the other hand, increased PP is strongly
lar disease (CVD) because it influences the arterial wall and associated with overall mortality in ESRD patients undergoing
is responsible for various cardiovascular events. In general, maintenance HD.8,9 Cardiovascular events are the leading cause
the relationship between blood pressure (systolic and mean of all-cause mortality in ESRD patients regardless of whether
artery blood pressure) and mortality is U-shaped in end-stage they receive HD or peritoneal dialysis (PD). The main patho-
renal disease (ESRD) patients receiving hemodialysis (HD).1,2 physiologic mechanism in those patients involves progression
Moreover, it is reported that low diastolic blood pressure (DBP) of the atherosclerotic process and loss of arterial compliance,
is also a significant risk factor for overall mortality in ESRD which leads to increased PP. Furthermore, whether the dialy-
patients on HD.3 The pulsatile component of blood pressure sis modality is a risk factor for CVD is still debatable. Recent
is estimated by the pulse pressure (PP), which is mainly influ- reports indicate that the outcome of patients suffering from
enced by the stiffness of large arteries, and is considered to be congestive heart failure or coronary disease is worse if they are
a risk factor for cardiovascular or all-cause mortality, both for PD recipients than if they are HD recipients.10,11 PP is clearly
research purpose and as a clinical predictor. Thus, some inves- associated with mortality in HD patients.8,9 However, few
tigators have indicated that PP could be a good predictor of studies have evaluated the association between PP and mortal-
all-cause and cardiovascular mortality in patients with under- ity in PD patients. It is also unknown whether the association
lying hypertension and various CVDs.4 between PP and mortality differs between PD and HD patients.
Notably, increased PP is frequently observed in chronic renal Thus, we conducted a single-center observational study in
failure patients5,6 and is associated with decreased arterial-wall a cohort of PD patients to determine whether increased PP is
1Division of Nephrology, Department of Internal Medicine, China Medical
associated with all-cause mortality in such patients.
University Hospital, Taichung, Taiwan; 2Division of Endocrinology and
Metabolism, Department of Internal Medicine, China Medical University Hospital, Methods
Taichung, Taiwan; 3Department of Endocrinology and Metabolism, School Study design and patients. This prospective study included
of Chinese Medicine College of Chinese Medicine, China Medical University,
Taichung, Taiwan. Correspondence: Ya-Fei Yang (w0951@yahoo.com.tw)
153 patients undergoing maintenance PD between 1 April 2005
and 30 September 2005 and was conducted in China Medical
Received 30 March 2008; first decision 5 August 2008; accepted 20 August 2008;
advance online publication 18 September 2008. doi:10.1038/ajh.2008.286 University Hospital in Taiwan. The inclusion criteria were reg-
© 2008 American Journal of Hypertension, Ltd. ular PD for at least 3 months before enrollment and clinical
stability for at least 3 months before entry without infectious to alternative renal replacement therapies (kidney transplan-
or other active diseases. The only exclusion criterion was a his- tation or HD) were censored at the time of transfer. Also,
tory of renal transplantation or maintenance of HD >3 months data for patients who were lost to follow-up but not trans-
prior to the study. The underlying kidney diseases included ferred to HD were censored from the survival analysis. If
chronic glomerulonephritis in 87 patients, hypertensive neph- a patient died within 3 months of transfer to HD, then his
rosclerosis in 16, diabetic nephropathy in 30, chronic intersti- or her health status was considered as the health status at
tial nephritis in 7, and other diseases in 13. All PD patients the time of PD failure. The observation period ended on 31
had double-cuff silastic Tenckhoff catheters inserted through December 2007. At the end of the follow-up, the status of all
the rectus muscle using standard surgical techniques and were patients was assessed and data on mortality were obtained
maintained on the Baxter Solo disconnect system and twin-bag for the entire cohort.
system. The dialysis regimen was prescribed by each patient’s
Endpoint and outcome analyses. Clinical outcomes in this Figure 1 | Frequency distribution of pulse pressure in peritoneal dialysis
study included actual patient survival. Patients transferred patients.
Table 1 | Comparison of baseline demographic, clinical, biochemical and dialysis indices of study patients stratified according to
tertiles of PP
Pulse pressure in tertiles
Lower (PP < 49 mm Hg) Middle (PP ≥ 49, < 67 mm Hg) Upper (PP ≥ 67 mm Hg)
(n = 51) (n = 51) (n = 51) P
Age (years) 51.8 ± 15.8 54.8 ± 14.2 56.8 ± 12.1 0.20
Gender (male) (%) 17 (33.3) 17 (33.3) 15 (29.4) 0.89
Diabetes mellitus (%) 3 (5.9) 3 (5.9) 24 (47.1) <0.001
Pre-existing CVD (%) 12 (23.5) 11 (21.6) 14 (27.5) 0.65
Results 80 and 100 mm Hg, and over 100 mm Hg, was 58.8, 26.2, 11.1,
Patient characteristics and 3.9, respectively. The percentage of patients with resid-
The enrolled patients (49 male and 104 female; mean age, ual renal function across the tertiles was 52.9 (lower), 52.9
54.5 ± 14.2 years) were on PD therapy for a median (inter- (middle), and 45.1 (upper), respectively (P = 0.43).
quartile range) duration of 27 (16–53) months. Of these,
67 (49.7%) had no residual renal function. Cardiovascular Comparisons of the different tertiles of PP
medications included statins, angiotensin receptor blockers/ Comparisons across PP tertiles (PP <49 mm Hg (lower ter-
angiotensin-converting enzyme inhibitors (ARB/ACEI), tile), PP between 49 and 67 mm Hg (middle tertile), and
antiplatelet regimens (aspirin, dipyridamole, or clopidogrel), PP ≥67 mm Hg (upper tertile)) are shown in Table 1. A signifi-
and β-antagonists in 13.1, 30.1, 15.0, and 35.3% of patients, cant increase in 4-h D/P creatinine (P < 0.01), serum triglyceride
respectively. The tertile cutoff points for PP were 49 and (P < 0.05), and fasting blood sugar (P < 0.001), and a significant
67 mm Hg; the distribution of PP at the time of study entry is decrease in serum albumin level (P < 0.001) were observed with
shown in Figure 1. The median PP (interquartile range) was increasing PP. More patients in the upper PP tertile had diabetes
56 mm Hg (range: 46–71 mm Hg). The percentage of patients mellitus (P < 0.001), received ACEI/ARB treatment (P < 0.01),
with PP below 60 mm Hg, between 60 and 80 mm Hg, between and received β-antagonist (P < 0.05) treatment.
Table 2 | Clinical outcome of patients according to the pulse pressure level at study baseline
Pulse pressure in tertiles
Lower (n = 51) Middle (n = 51) Upper (n = 51) P
Outcome
Died on dialysis (n (%)) 6 (11.8) 7 (13.7) 14 (27.5) <0.05
Alive on peritoneal dialysis (n (%)) 36 (70.6) 34 (66.7) 27 (52.9) 0.065
Transferred to hemodialysis (n (%)) 8 (15.7) 8 (15.7) 9 (17.6) 1.00
Transplanted (n (%)) 0 (0) 1 (2.0) 0 (0) 0.22
Loss of follow-up (n (%)) 1 (2.0) 1 (2.0) 1 (2.0) 1.00
1.0
Patient survival and causes of death in relation to PP
During the study period, 28 patients were switched to HD,
one received renal transplantation, and three transferred to 0.8
0.6
survival analysis. The causes of death (Table 2) were CVDs
(10 patients), peritonitis (six patients), nonperitonitis infec-
tions (seven patients), malignancy (one patient), hollow 0.4
organ rupture (two patients), and acute pancreatitis (one
P < 0.05
patient). The remaining 97 patients were administratively Upper tertile
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