Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Time of hemodialysis and risk of intradialytic hypotension and intradialytic hypertension in maintenance hemodialysis

Journal of Human Hypertension volume 37, pages 880–890 (2023)Cite this article

Subjects

Abstract

Intradialytic hypotension and intradialytic hypertension are complications of hemodialysis (HD) associated with a higher risk of cardiovascular disease (CVD) and death. Blood pressure (BP) normally fluctuates in a circadian pattern, but whether the risk of intradialytic hypotension and intradialytic hypertension varies according to the time of the HD session is unknown. We analyzed two cohorts of thrice-weekly maintenance HD (N = 1838 patients/n = 64,503 sessions from the Hemodialysis [HEMO] Study, and N = 3302 patients/n = 33,590 sessions from Satellite Healthcare). Random effects logistic regression models examined the association of HD start time (at or before 9:00 a.m. [early AM], between 9:01 a.m. and 12:00 p.m. [late AM], and at or after 12:01 p.m. [PM]) with intradialytic hypotension (defined as nadir intra-HD systolic BP (SBP) < 90 mmHg if pre-HD SBP < 160 mmHg, or <100 mmHg if pre-HD SBP ≥ 160 mmHg) and intradialytic hypertension (SBP increase ≥ 10 mmHg from pre-HD to post-HD). Compared to early AM, late AM and PM were associated with an 8% (aOR 0.92, 95% CI 0.83–1.02) and a 16% (aOR 0.84, 95% CI 0.75–0.95) lower risk of intradialytic hypotension in HEMO, respectively. Conversely, compared to early AM, a monotonic higher risk of intradialytic hypertension was observed for late AM (aOR 1.23, 95% CI 1.12–1.35) and PM (aOR 1.41, 95% CI 1.27–1.56) in HEMO. These findings were consistent in Satellite. In two large cohorts of maintenance HD, we observed a monotonic lower risk of intradialytic hypotension and a monotonic higher risk of intradialytic hypertension with later dialysis start times. Whether HD treatment allocation to certain times of the day in hypotensive-prone or hypertensive-prone patients improves outcomes deserves further investigation.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Adjusted splines of the risk of intradialytic hypotension according to hemodialysis session start time in the Hemodialysis Study.
Fig. 2: Adjusted splines of the risk of intradialytic hypotension according to hemodialysis session start time in the Satellite cohort.
Fig. 3: Adjusted splines of the risk intradialytic hypertension according to hemodialysis session start time in the Hemodialysis Study.
Fig. 4: Adjusted splines of the risk of intradialytic hypertension according to hemodialysis session start time in the Satellite cohort.

Similar content being viewed by others

Data availability

Data from HEMO were obtained from the National Institute of Diabetic and Digestive and Kidney Diseases (NIDDK) data repository. Anonymized data were provided by Satellite Healthcare.

References

  1. United States Renal Data System. 2022 USRDS annual data report: epidemiology of kidney disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2022.

  2. Kramer A, Pippias M, Noordzij M, Stel VS, Afentakis N, Ambühl PM, et al. The European Renal Association—European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report 2015: a summary. Clin Kidney J. 2018;11:108–22.

    Article  PubMed  PubMed Central  Google Scholar 

  3. National Kidney Foundation. KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update. Am J Kidney Dis. 2015;66:884–930.

  4. Flythe JE, Xue H, Lynch KE, Curhan GC, Brunelli SM. Association of mortality risk with various definitions of intradialytic hypotension. J Am Soc Nephrol. 2015;26:724–34.

    Article  CAS  PubMed  Google Scholar 

  5. Reeves PB, Mc Causland FR. Mechanisms, clinical implications, and treatment of intradialytic hypotension. Clin J Am Soc Nephrol. 2018;13:1297–303.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Sars B, van der Sande FM, Kooman JP. Intradialytic hypotension: mechanisms and outcome. Blood Purif. 2020;49:158–67.

    Article  PubMed  Google Scholar 

  7. Chang TI, Paik J, Greene T, Desai M, Bech F, Cheung AK, et al. Intradialytic hypotension and vascular access thrombosis. J Am Soc Nephrol. 2011;22:1526–33.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Shoji T, Tsubakihara Y, Fujii M, Imai E. Hemodialysis-associated hypotension as an independent risk factor for two-year mortality in hemodialysis patients. Kidney Int. 2004;66:1212–20.

    Article  PubMed  Google Scholar 

  9. Yu J, Liu Z, Shen B, Teng J, Zou J, Ding X. Intradialytic hypotension as an independent risk factor for long-term mortality in maintaining hemodialysis patients: a 5-year follow-up cohort study. Blood Purif. 2018;45:320–6.

    Article  CAS  PubMed  Google Scholar 

  10. Chou JA, Streja E, Nguyen DV, Rhee CM, Obi Y, Inrig JK, et al. Intradialytic hypotension, blood pressure changes and mortality risk in incident hemodialysis patients. Nephrol Dial Transpl. 2018;33:149–59.

    Article  CAS  Google Scholar 

  11. Flythe JE, Chang TI, Gallagher MP, Lindley E, Madero M, Sarafidis PA, et al. Blood pressure and volume management in dialysis: conclusions from a kidney disease: improving global outcomes (KDIGO) controversies conference. Kidney Int. 2020;97:861–76.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Georgianos PI, Sarafidis PA, Zoccali C. Intradialysis hypertension in end-stage renal disease patients: clinical epidemiology, pathogenesis, and treatment. Hypertension. 2015;66:456–63.

    Article  CAS  PubMed  Google Scholar 

  13. Douma LG, Gumz ML. Circadian clock-mediated regulation of blood pressure. Free Radic Biol Med. 2018;119:108–14.

    Article  CAS  PubMed  Google Scholar 

  14. Rodby RA, Vonesh EF, Korbet SM. Blood pressures in hemodialysis and peritoneal dialysis using ambulatory blood pressure monitoring. Am J Kidney Dis. 1994;23:401–11.

    Article  CAS  PubMed  Google Scholar 

  15. Karpetas A, Sarafidis PA, Georgianos PI, Protogerou A, Vakianis P, Koutroumpas G, et al. Ambulatory recording of wave reflections and arterial stiffness during intra- and interdialytic periods in patients treated with dialysis. Clin J Am Soc Nephrol. 2015;10:630–8.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Narita I, Okada M, Omori S, Nagai M, Sawanaka N, Kondo D, et al. The circadian blood pressure rhythm in non-diabetic hemodialysis patients. Hypertens Res. 2001;24:111–7.

    Article  CAS  PubMed  Google Scholar 

  17. Santos SF, Mendes RB, Santos CA, Dorigo D, Peixoto AJ. Profile of interdialytic blood pressure in hemodialysis patients. Am J Nephrol. 2003;23:96–105.

    Article  PubMed  Google Scholar 

  18. Abbott KC, Reynolds JC, Trespalacios FC, Cruess D, Agodoa LY. Survival by time of day of hemodialysis: analysis of United States Renal Data System Dialysis Morbidity and Mortality Waves III/IV. Am J Kidney Dis. 2003;41:796–806.

    Article  PubMed  Google Scholar 

  19. Bliwise DL, Kutner NG, Zhang R, Parker KP. Survival by time of day of hemodialysis in an elderly cohort. JAMA. 2001;286:2690–4.

    Article  CAS  PubMed  Google Scholar 

  20. Ng YH, Meyer KB, Kusek JW, Yan G, Rocco MV, Kimmel PL, et al. Hemodialysis timing, survival, and cardiovascular outcomes in the Hemodialysis (HEMO) Study. Am J Kidney Dis. 2006;47:614–24.

    Article  PubMed  Google Scholar 

  21. Eknoyan G, Beck GJ, Cheung AK, Daugirdas JT, Greene T, Kusek JW, et al. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med. 2002;347:2010–9.

    Article  PubMed  Google Scholar 

  22. Greene T, Beck GJ, Gassman JJ, Gotch FA, Kusek JW, Levey AS, et al. Design and statistical issues of the hemodialysis (HEMO) study. Control Clin Trials. 2000;21:502–25.

    Article  CAS  PubMed  Google Scholar 

  23. Mc Causland FR, Waikar SS. Association of predialysis calculated plasma osmolarity with intradialytic blood pressure decline. Am J Kidney Dis. 2015;66:499–506.

    Article  Google Scholar 

  24. Singh AT, Waikar SS, Mc Causland FR. Association of different definitions of intradialytic hypertension with long-term mortality in hemodialysis. Hypertension. 2022;79:855–62.

    Article  CAS  PubMed  Google Scholar 

  25. Kanbay M, Ertuglu LA, Afsar B, Ozdogan E, Siriopol D, Covic A, et al. An update review of intradialytic hypotension: concept, risk factors, clinical implications and management. Clin Kidney J. 2020;13:981–93.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Chan CT, Chertow GM, Daugirdas JT, Greene TH, Kotanko P, Larive B, et al. Effects of daily hemodialysis on heart rate variability: results from the Frequent Hemodialysis Network (FHN) Daily Trial. Nephrol Dial Transpl. 2014;29:168–78.

    Article  Google Scholar 

  27. Owen PJ, Priestman WS, Sigrist MK, Lambie SH, John SG, Chesterton LJ, et al. Myocardial contractile function and intradialytic hypotension. Hemodial Int. 2009;13:293–300.

    Article  PubMed  Google Scholar 

  28. Iatridi F, Theodorakopoulou MP, Papagianni A, Sarafidis P. Intradialytic hypertension: epidemiology and pathophysiology of a silent killer. Hypertens Res. 2022;45:1713–25.

    Article  PubMed  Google Scholar 

  29. Gutiérrez-Adrianzén OA, Moraes ME, Almeida AP, Lima JW, Marinho MF, Marques AL, et al. Pathophysiological, cardiovascular and neuroendocrine changes in hypertensive patients during the hemodialysis session. J Hum Hypertens. 2015;29:366–72.

    Article  PubMed  Google Scholar 

  30. Riganello F, Prada V, Soddu A, di Perri C, Sannita WG. Circadian Rhythms and Measures of CNS/Autonomic Interaction. Int J Environ Res Public Health. 2019;16:2336.

  31. Baschieri F, Cortelli P. Circadian rhythms of cardiovascular autonomic function: physiology and clinical implications in neurodegenerative diseases. Auton Neurosci. 2019;217:91–101.

    Article  CAS  PubMed  Google Scholar 

  32. Veerman DP, Imholz BP, Wieling W, Wesseling KH, van Montfrans GA. Circadian profile of systemic hemodynamics. Hypertension. 1995;26:55–9.

    Article  CAS  PubMed  Google Scholar 

  33. Liu M, Takahashi H, Morita Y, Maruyama S, Mizuno M, Yuzawa Y, et al. Non-dipping is a potent predictor of cardiovascular mortality and is associated with autonomic dysfunction in haemodialysis patients. Nephrol Dial Transpl. 2003;18:563–9.

    Article  Google Scholar 

  34. Liu W, Ye H, Tang B, Song Z, Sun Z, Wen P, et al. Profile of interdialytic ambulatory blood pressure in a cohort of Chinese patients. J Hum Hypertens. 2014;28:677–83.

    Article  CAS  PubMed  Google Scholar 

  35. Smolensky MH, Hermida RC, Portaluppi F. Circadian mechanisms of 24-hour blood pressure regulation and patterning. Sleep Med Rev. 2017;33:4–16.

    Article  PubMed  Google Scholar 

  36. Sheng Y, Zhu L. The crosstalk between autonomic nervous system and blood vessels. Int J Physiol Pathophysiol Pharm. 2018;10:17–28.

    CAS  Google Scholar 

  37. Portaluppi F, Bagni B, degli Uberti E, Montanari L, Cavallini R, Trasforini G, et al. Circadian rhythms of atrial natriuretic peptide, renin, aldosterone, cortisol, blood pressure and heart rate in normal and hypertensive subjects. J Hypertens. 1990;8:85–95.

  38. Van Buren PN, Kim C, Toto R, Inrig JK. Intradialytic hypertension and the association with interdialytic ambulatory blood pressure. Clin J Am Soc Nephrol. 2011;6:1684–91.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Bikos A, Angeloudi E, Memmos E, Loutradis C, Karpetas A, Ginikopoulou E, et al. A comparative study of short-term blood pressure variability in hemodialysis patients with and without intradialytic hypertension. Am J Nephrol. 2018;48:295–305.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We thank the Hemodialysis Study Investigators and Satellite Healthcare for their contributions of data for this publication.

Funding

The Hemodialysis Study was conducted by the Hemodialysis Study Investigators and supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The data from the Hemodialysis study reported here were supplied by the NIDDK Central Repositories. This manuscript was not prepared in collaboration with Investigators of the Hemodialysis Study and does not necessarily reflect the opinions or views of the Hemodialysis Study investigators, the NIDDK Central Repositories, or the NIDDK.

Author information

Author notes

  1. These authors contributed equally: Murad Alostaz, Simon Correa.

Authors and Affiliations

  1. Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA

    Murad Alostaz

  2. Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA

    Simon Correa

  3. Yale New Haven Hospital, New Haven, CT, USA

    Simon Correa

  4. Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Simon Correa & Finnian R. Mc Causland

  5. Harvard Medical School, Boston, MA, USA

    Simon Correa & Finnian R. Mc Causland

  6. Queen’s University Belfast, Belfast, Northern Ireland

    Gavin S. Lundy

  7. Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA, USA

    Sushrut S. Waikar

Authors
  1. Murad Alostaz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Simon Correa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gavin S. Lundy
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sushrut S. Waikar
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Finnian R. Mc Causland
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Research idea and study design: MA and SC; data acquisition: SSW and FRMC; data analysis/interpretation: all authors; statistical analysis: SC and FRMC; supervision or mentorship: FRMC and SSW. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Simon Correa.

Ethics declarations

Competing interests

The authors declare that they have no relevant conflict interest related to this manuscript. FRMC reports research funding from NIH, Satellite Healthcare, Fifth Eye, and Advanced Instruments paid directly to his institution; consulting fees from Advanced Instruments, GSK, and Zydus Therapeutics. SSW reports personal fees from Public Health Advocacy Institute, CVS, Roth Capital Partners, Kantum Pharma, Mallinckrodt, Wolters Kluewer, GE Health Care, GSK, Mass Medical International, Barron and Budd (vs. Fresenius), JNJ, Venbio, Strataca, Takeda, Cerus, Pfizer, Bunch and James, and grants and personal fees from Allena Pharmaceuticals. The results presented in this paper have not been published previously in whole or part, except in abstract format. SC, MA and GSL have nothing to disclose.

Ethical approval

The HEMO Study protocol was approved at each clinical center affiliated with the participating dialysis units by institutional review boards, and written informed consent was obtained from all study subjects. Anonymized data were provided by Satellite healthcare and the study protocol was deemed exempt by the Partners Healthcare Institutional Review Board.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Alostaz, M., Correa, S., Lundy, G.S. et al. Time of hemodialysis and risk of intradialytic hypotension and intradialytic hypertension in maintenance hemodialysis. J Hum Hypertens 37, 880–890 (2023). https://doi.org/10.1038/s41371-022-00799-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41371-022-00799-2

Search

Advanced search

Quick links