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 Table of Contents 
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 1488-1491  

The effect of intensive hemodialysis on LVH regression and blood pressure control in ESRD patients


1 Atherosclerosis Research Center, Ahvaz Jondishapour University of Medical Sciences, Ahvaz, Iran
2 Chronic Renal Failure Research Center, Ahvaz Jondishapour University of Medical Sciences, Ahvaz, Iran
3 Department of Biostatistics and Epidemiology, School of Public Health, Ahvaz Jondishapour University of Medical Sciences, Ahvaz, Iran

Date of Submission26-Oct-2019
Date of Decision30-Jan-2020
Date of Acceptance05-Feb-2020
Date of Web Publication26-Mar-2020

Correspondence Address:
Dr. Shahla A Halili
Assistant Professor of Nephrology, Chronic Renal Failure Research Center, Ahvaz Jondishapour University of Medical Sciences, Ahvaz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_946_19

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  Abstract 


Introduction: Cardiovascular diseases are considered the major cause of death in dialysis patients with end-stage renal disease (ESRD). Recently, intensive hemodialysis has increasingly used and replaced conventional hemodialysis. The present study aimed to evaluate the effect of intensive hemodialysis on LVH regression and blood pressure control. Methods: The present study is self-control, pre- and post-intervention clinical trial on hemodialysis ESRD patients with hypertension (52.5% female with a mean age of 55.55 ± 12.96), who were admitted to Imam Khomeini Hospitals, Golestan Ahvaz in 1396. All patients underwent intensive hemodialysis treatment 4 times a week for 2 months. 2-D color Doppler echocardiography was performed for all patients before the intervention and following 2 months of intensive hemodialysis. The results of chest echocardiographic were used to determine left ventricular thickness. Results: In this study, 40 patients with hypertension were studied. The results of this study showed a significant decrease (P < 0.0001) in the levels of LVH, SBP, DBP and mean BP after intervention in ESRD patients. The level of LVH was decreased from 15.42 ± 1.67 mmHg to 13.86 ± 1.39 mmHg, SBP from 161.50 ± 12.16 mmHg to 141.12 ± 8.87 mmHg, DBP from 25.25 ± 5.15 mmHg to 81/75 ± 2.89 mmHg, and mean BP from 114.66 ± 6.82 mmHg to 101/54 ± 3.98 mmHg. Conclusion: Based on the results, it can be concluded that intensive hemodialysis resulted in improved LVH regression and blood pressure control, and fewer requirements for blood pressure-lowering medications.

Keywords: End-stage renal disease, hypertension, intensive dialysis, left ventricle hypertrophy


How to cite this article:
Darabi F, Halili SA, Moradi M. The effect of intensive hemodialysis on LVH regression and blood pressure control in ESRD patients. J Family Med Prim Care 2020;9:1488-91

How to cite this URL:
Darabi F, Halili SA, Moradi M. The effect of intensive hemodialysis on LVH regression and blood pressure control in ESRD patients. J Family Med Prim Care [serial online] 2020 [cited 2020 Jul 4];9:1488-91. Available from: http://www.jfmpc.com/text.asp?2020/9/3/1488/281227




  Introduction Top


Cardiovascular diseases are considered the major cause of death in dialysis patients with end-stage renal disease (ESRD).[1] Most of the hemodialysis patients undergo dialysis 3 times a week which each session takes about 4 hours (3 hours and 37 minutes).[2] Recently, intensive hemodialysis has increasingly used and replaced conventional hemodialysis. The result of studies have shown that intensive hemodialysis resulted in improving the uremic toxicity clearance, LVH regression and blood pressure control, reducing left ventricular mass (LVM) and other cardiovascular outcomes, thereby improving sleep quality and quality of life.[3],[4],[5],[6] Hypertension is one of the clinical characteristics of ESRD patients. Hypertensive nephropathy is the underlying cause of ESRD incidence in approximately 30% of patients, so that, the prevalence of hypertension in patients with newly diagnosed ESRD is more than 85%. Pre-dialysis systolic blood pressure (SBP) is about 150 mmHg in patients undergoing conventional hemodialysis. Generally, a U-shaped relationship exists between pre-dialysis SBP and mortality risk.[7] The present study aimed to evaluate the effect of intensive hemodialysis on LVH regression and blood pressure control in ESRD patients.


  Methods Top


The present study aimed to evaluate the effect of intensive hemodialysis on LVH regression and blood pressure control. In this study, after receiving permission from Jundishapur University of Medical Sciences, Ahvaz, a group of ESRD patients with LVH and hypertension admitted to Imam Khomeini and Golestan Hospitals in Ahvaz were asked to participate. Patients eligible for the study were selected according to inclusion and exclusion criteria. Before treatment, written informed consent was obtained for all patients. This prospective clinical trial was approved by the Research Ethics Committee of the Ahvaz Jundishapur University of Medical Sciences (Code: IR.AJUMS.REC.1396.911).

Inclusion criteria

  • Over 35 years old
  • SBP ≥140 mmHg
  • DBP ≥90 mmHg
  • LVH ≥12 mm
  • Satisfaction with participation in the study.


Exclusion criteria

• Left ventricular hypertrophy due to severe valvular disease such as severe AS or cardiac myopathy hypertrophy.

Intervention

At first, demographic characteristics and medical history of patients including age, sex, weight, BMI, duration of ESRD diagnosis, history of hypertension, history of diabetes, history of smoking, medications used, and dialysis duration were recorded. Afterward, all patients underwent intensive hemodialysis treatment for 2 months. Intensive hemodialysis is defined as a hemodialysis treatment for 16 hours and over per week, which is determined on the basis of the prescription regimen on the last day of previous dialysis.[8] In all patients, the levels of SBP, DBP and mean BP were evaluated before and after intensive dialysis. 2D echocardiography was also performed to measure the level of left ventricular hypertrophy before and after intensive dialysis.

Statistical tests

Statistical indicators used to describe the data included mean, standard deviation, min, max, frequency and percentage. Kolmogorov-Smirnov test was applied to examine the normality of the data. Later, due to the non-normal distribution of data, nonparametric tests were used. The obtained results before and after the intervention were compared using the Wilcoxon signed-rank test. Mann-Whitney test and Spearman correlation were applied to examine the relationship between variables. The significance level was considered to be 0.05 in all tests.


  Results Top


The basic characteristics of ESRD patients are presented in [Table 1]. The mean age of participants was 55.55 ± 12.96 (ranged from 35 to 85) years. The mean age of disease incidence was 3.45 ± 2.42 years (ranged from 1 to 9) years. The results of drug use showed that Eprex with 87.5% was the most prevalent and Carvedilol with 52.5% was the least prevalent drugs used in under-studied patients.
Table 1: Basic characteristics of ESRD patients

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Numbers are shown as mean ± standard deviation (maximum-minimum) or frequency (percent).

The comparison results of the data related to pre- and post-intensive hemodialysis for the studied patients are presented in [Table 2]. In the present study, the levels of LVH, SBP, DBP and mean BP for ESRD patients were significantly decreased after the intervention (P < 0.0001).
Table 2: Comparison of pre. and post.intensive hemodialysis in ESRD patients

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The result of Spearman correlation test showed no significant relationship between LVH reduction and either of the patient age (r = 0.265, P = 0.098) or duration of disease diagnosis (r = 0.014, P = 0.941) at the end of the study. Patient age had a direct and significant relationship with changes in systolic blood pressure (r = 0.341, P = 0.032), diastolic blood pressure (r = 0.423, P = 0.005) and mean BP (r = 0.465, P = 0.002). However, there was no significant relationship between duration of disease diagnosis and changes in systolic blood pressure (r = -0.06, P = 0.712), diastolic blood pressure (r = -0.02, P = 0.990912) and mean BP (R = -0.032, P = 0.864). The results of Mann-Whitney test showed that LVH changes and systolic and diastolic blood pressures had no significant relationship with sex, smoking, and the use of CaCO3, nephrotic, Renagel and Eprex (P < 0.05). However, at the end of the intervention, the reduction in LVH, systolic and diastolic blood pressure and mean BP levels were significantly higher in patients taking Amillodopamin, Valsartan, Lasix, and carvediol compared to those who did not use these drugs (P < 0.05).


  Discussion Top


Several factors are involved in the development of hypertension, including permanent hypervolemia and increased environmental resistance. In the case of hemodialysis by 3 times a week, blood pressure increases during the periods between the dialysis sessions, which is associated with an increase in patient's weight during these periods, especially in older patients with higher dry weights. Increased peripheral resistance may be associated with impaired activation of the sympathetic nervous system due to higher concentrations of norepinephrine in plasma.[7] Sodium and water retention are the main causes of hypertension in dialysis patients.[9]

Various clinical trials have shown that intensive hemodialysis reduces blood pressure and the need for using antihypertensive pills. During the first 2 months of intensive hemodialysis (3 times a week), the short daily program reduced the pre-dialysis SBP to 7.7 mmHg, and the nightly hemodialysis program further reduced this to 7.3 mmHg. This improvement continued after 12 months of intensive hemodialysis. The daily short-term hemodialysis program also reduced the average number of antihypertensive drugs (from 1.7 to 1.0 in one year), and the percentage of patients who did not use these drugs increased from 21% to 47%. Nightly hemodialysis program resulted in a significant reduction in peripheral resistance and plasma norepinephrine, as well as in endothelium-dependent vasodilation. According to the results, it can be concluded that the intensive hemodialysis reduces blood pressure and the need for using antihypertensive pills.

Recently, a large number of studies have investigated the effect of intensive hemodialysis on cardiovascular parameters. For example, Kostenko et al.[10] studied the effects of conventional hemodialysis and intensive hemodialysis on blood pressure in US society and reported that there is a significant decrease in systolic (-7.7 mmHg) and diastolic (-1.9 mmHg) blood pressures after 2 months of daily intensive hemodialysis compared to pre-dialysis observations. In their meta-analysis in Canada, Susantitaphong et al.[11] investigated the effects of intensive hemodialysis on cardiovascular parameters. The results showed that intensive hemodialysis significantly reduced LVMI compared to the onset of the study (-39.8 to -22.5 g/m2). They also found a significant decrease in mean systolic and diastolic blood pressures, and in the number of antihypertensive medications. Ayus et al.[12] compared the effects of daily short-term and conventional hemodialysis on left ventricular hypertrophy and inflammatory markers in the US. The result of their study showed that after 12 months of intervention, the group receiving daily short-term hemodialysis experienced a significant decrease in LVMI level by 30% (from 154 ± 33 to 108 ± 25). Moreover, CRP and Erythropoietin Resistance Index were significantly decreased in this group. The results of the present study showed that intensive hemodialysis improves LVH regression and blood pressure control, which is consistent with the results of previous studies.


  Conclusion Top


This study investigated the effect of a 2-months intensive hemodialysis on LVH regression and blood pressure control in ESRD patients. The results showed a significant decrease in the levels of LVH, SBP, DBP and mean BP after intensive hemodialysis of ESRD patients, which led to a decrease in the need for antihypertensive medications in these patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Duran M, Unal A, Inanc MT, Esin F, Yilmaz Y, Ornek E. Effect of maintenance hemodialysis on diastolic left ventricular function in end-stage renal disease. Clinics (Sao Paulo) 2010;65:979-84.  Back to cited text no. 1
    
2.
Assimon MM, Wang L, Flythe JE. Intradialytic hypertension frequency and short-term clinical outcomes among individuals receiving maintenance hemodialysis. Am J Hypertens 2018;31:329-39.  Back to cited text no. 2
    
3.
FHN Trial Group, Chertow GM, Levin NW, Beck GJ, Depner TA, Eggers PW, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med 2010;363:2287-300.  Back to cited text no. 3
    
4.
Pugh D, Gallacher PJ, Dhaun N. Management of hypertension in chronic kidney disease. Drugs 2019;79:365-79.  Back to cited text no. 4
    
5.
Culleton BF, Walsh M, Klarenbach SW, Mortis G, Scott-Douglas N, Quinn RR, et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: A randomized controlled trial. JAMA 2007;298:1291-9.  Back to cited text no. 5
    
6.
Friesen T, Jassal DS, Zhu M, Eng F, Rigatto C, Tangri N, et al. Cardiovascular remodeling during long-term nocturnal home hemodialysis. Clin Exp Nephrol 2015;19:514-20.  Back to cited text no. 6
    
7.
Bakris GL, Burkart JM, Weinhandl ED, McCullough PA, Kraus MA. Intensive hemodialysis, blood pressure, and antihypertensive medication use. Am J Kidney Dis 2016;68:15-23.  Back to cited text no. 7
    
8.
Trinh E, Chan CT. Intensive home hemodialysis results in regression of left ventricular hypertrophy and better clinical outcomes. Am J Nephrol 2016;44:300-7.  Back to cited text no. 8
    
9.
Matrin KB, Klinger JR, Rounds SI. Pulmonary arterial hypertension: New insights and new hope. Respirology 2006;11:6-17.  Back to cited text no. 9
    
10.
Banegas JR, Ruilope LM, de la Sierra A, Vinyoles E, Gorostidi M, de la Cruz JJ, et al. Relationship between clinic and ambulatory blood-pressure measurements and mortality. N Engl J Med 2018;378:1509-20.  Back to cited text no. 10
    
11.
Susantitaphong P, Koulouridis I, Balk EM, Madias NE, Jaber BL. Effect of frequent or extended hemodialysis on cardiovascular parameters: A meta-analysis. Am J Kidney Dis 2012;59:689-99.  Back to cited text no. 11
    
12.
Ayus JC, Mizani MR, Achinger SG, Thadhani R, Go AS, Lee S. Effects of short daily versus conventional hemodialysis on left ventricular hypertrophy and inflammatory markers: A prospective, controlled study. J Am Soc Nephrol 2005;16:2778-88.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2]



 

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