Skip to main content

Thank you for visiting 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.

Changes in pre-dialysis blood pressure variability in the first year of dialysis associate with mortality in European hemodialysis patients: a retrospective cohort study on behalf of the MONDO Initiative


Pre-hemodialysis systolic blood pressure variability (pre-HD SBPV) has been associated with outcomes. The association of a change in pre-HD SBPV over time with outcomes, and predictors of this change, has not yet been studied. Therefore, we studied this in a cohort of 8825 incident hemodialysis (HD) patients from the European Monitoring Dialysis Outcomes Initiative database. Patient level pre-HD SBPV was calculated as the standard deviation of the residuals of a linear regression model of systolic blood pressure (SBP) over time divided by individual mean SBP in the respective time periods. The pre-HD SBPV difference between months 1–6 and 7–12 was used as an indicator of pre-HD SBPV change. The association between pre-HD SBPV change and all-cause mortality in year 2 was analyzed by multivariate Cox models. Predictors of pre-HD SBPV change was determined by logistic regression models. We found the highest pre-HD SBPV tertile, in the first 6 months after initiation of HD, had the highest mortality rates (adjusted HR 1.44 (95% confidence intervals (95% CI): 1.15–1.79)). An increase in pre-HD SBPV between months 1–6 and 7–12 was associated with an increased risk of mortality in year 2 (adjusted HR 1.29 (95% CI: 1.05–1.58)) compared with stable pre-HD SPBV. A pre-HD SBPV increase was associated with female gender, higher mean pre-HD SBP and pulse pressure, and lower HD frequency.

This is a preview of subscription content

Access options

Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1
Fig. 2


  1. Chang TI, Flythe JE, Brunelli SM, Muntner P, Greene T, Cheung AK, et al. Visit-to-visit systolic blood pressure variability and outcomes in hemodialysis. J Hum Hypertens. 2014;28:18–24.

    CAS  Article  Google Scholar 

  2. Shafi T, Sozio SM, Bandeen-Roche KJ, Ephraim PL, Luly JR, St Peter WL, et al. Predialysis systolic BP variability and outcomes in hemodialysis patients. J Am Soc Nephrol. 2014;1–11.

  3. Selvarajah V, Pasea L, Ojha S, Wilkinson IB, Tomlinson LA. Pre-dialysis systolic blood pressure-variability is independently associated with all-cause mortality in incident haemodialysis patients. PLoS One. 2014;9.

  4. Di Iorio B, Pota A, Sirico ML, Torraca S, Di Micco L, Rubino R, et al. Blood pressure variability and outcomes in chronic kidney disease. Nephrol Dial Transplant. 2012;27:4404–10.

    Article  Google Scholar 

  5. McMullan CJ, Bakris GL, Phillips RA, Forman JP. Association of BP variability with mortality among African Americans with CKD. Clin J Am Soc Nephrol. 2013;8:731–8.

    Article  Google Scholar 

  6. Hata J, Arima H, Rothwell PM, Woodward M, Zoungas S, Anderson C, et al. Effects of visit-to-visit variability in systolic blood pressure on macrovascular and microvascular complications in patients with type 2 diabetes mellitus: the advance trial. Circulation. 2013;128:1325–34.

    Article  Google Scholar 

  7. Tai C, Sun Y, Dai N, Xu D, Chen W, Wang J, et al. Prognostic significance of visit-to-visit systolic blood pressure variability: a meta-analysis of 77,299 patients. J Clin Hypertens. 2015;17:107–15.

    Article  Google Scholar 

  8. Rothwell PM, Howard SC, Dolan E, O’Brien E, Dobson JE, Dahlof B, et al. Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. Lancet. 2010;375:895–905.

  9. Mallamaci F, Minutolo R, Leonardis D, D’Arrigo G, Tripepi G, Rapisarda F, et al. Long-term visit-to-visit office blood pressure variability increases the risk of adverse cardiovascular outcomes in patients with chronic kidney disease. Kidney Int. 2013;84:381–9.

    CAS  Article  Google Scholar 

  10. McMullan CJ, Lambers Heerspink HJ, Parving H-H, Dwyer JP, Forman JP, de Zeeuw D. Visit-to-visit variability in blood pressure and kidney and cardiovascular outcomes in patients with type 2 diabetes and nephropathy: a post hoc analysis from the RENAAL study and the irbesartan diabetic nephropathy trial. Am J Kidney Dis. 2014;64:714–22.

    Article  Google Scholar 

  11. Flythe JE, Brunelli SM. Blood pressure variability among chronic dialysis patients: recent advances in knowledge. Curr Opin Nephrol Hypertens. 2015;24:163–9.

    Article  Google Scholar 

  12. Mallamaci F, Tripepi G. Blood pressure variability in chronic kidney disease patients. Blood Purif. 2013;36:58–62.

    Article  Google Scholar 

  13. Aoki Y, Kai H, Kajimoto H, Kudo H, Takayama N, Yasuoka S, et al. Large blood pressure variability aggravates arteriolosclerosis and cortical sclerotic changes in the kidney in hypertensive rats. Circ J. 2014.

  14. Mcintyre CW. Recurrent circulatory stress: the dark side of dialysis. Semin Dialysis. 2010;23:449–51.

    Article  Google Scholar 

  15. Von Gersdorff GD, Usvyat L, Marcelli D, Grassmann A, Marelli C, Etter M. et al. Monitoring dialysis outcomes across the world—the MONDO global database consortium. Blood Purif. 2014;36:165–72.

  16. Usvyat LA, Haviv YS, Etter M, Kooman J, Marcelli D, Marelli C, et al. The Monitoring Dialysis Outcomes (MONDO) initiative. Blood Purif. 2013;36:37–48.

    Article  Google Scholar 

  17. Di Iorio B, Di Micco L, Torraca S, Sirico ML, Guastaferro P, Chiuchiolo L, et al. Variability of blood pressure in dialysis patients: a new marker of cardiovascular risk? J Nephrol. 2013;26:173–82.

    Article  Google Scholar 

  18. Brunelli SM, Thadhani RI, Lynch KE, Ankers ED, Joffe MM, Boston R, et al. Association between long-term blood pressure variability and mortality among incident hemodialysis patients. Am J Kidney Dis. 2008;52:716–26.

    Article  Google Scholar 

  19. Su D-F. Treatment of hypertension based on measurement of blood pressure variability: lessons from animal studies. Curr Opin Cardiol. 2006;21:486–91.

    Article  Google Scholar 

  20. Rothwell PM. Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension. Lancet. 2010;375:938–48.

  21. Agarwal R. Hypertension and survival in chronic hemodialysis patients-past lessons and future opportunities. Kidney Int. 2005;67:1–13.

    Article  Google Scholar 

  22. Burton JO, Jefferies HJ, Selby NM, McIntyre CW. Hemodialysis-induced cardiac injury: determinants and associated outcomes. Clin J Am Soc Nephrol. 2009;4:914–20.

    Article  Google Scholar 

  23. Miao C-Y, Xie H-H, Zhan L-S, Su D-F. Blood pressure variability is more important than blood pressure level in determination of end-organ damage in rats. J Hypertens. 2006;24:1125–35.

    CAS  Article  Google Scholar 

  24. Sipahioglu MH, Usvyat L, Liu L, Abbas SR, Raimann JG, Rosales L, et al. Early systolic blood pressure changes in incident hemodialysis patients are associated with mortality in the first year. Kidney Blood Press Res. 2012;35:663–70.

    Article  Google Scholar 

  25. Bradbury BD, Fissell RB, Albert JM, Anthony MS, Critchlow CW, Pisoni RL, et al. Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am Soc Nephrol. 2007;2:89–99.

    Article  Google Scholar 

  26. Chazot C, Vo-Van C, Deleaval P, Lorriaux C, Hurot JM, Mayor B, et al. Predialysis systolic blood pressure evolution in incident hemodialysis patients: effects of the dry weight method and prognostic value. Blood Purif 2012;33:275–83.

    Article  Google Scholar 

  27. Flythe JE, Inrig JK, Shafi T, Chang TI, Cape K, Dinesh K, et al. Association of intradialytic blood pressure variability with increased all-cause and cardiovascular mortality in patients treated with long-term hemodialysis. Am J Kidney Dis. 2013;61:966–74.

    Article  Google Scholar 

  28. Lambie SH, Taal MW, Fluck RJ, McIntyre CW. Analysis of factors associated with variability in haemodialysis adequacy. Nephrol Dial Transplant. 2004;19:406–12.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Marijke J. E. Dekker.

Ethics declarations

Conflict of interest

BC and LAU are employees of Fresenius Medical Care and may hold stock in the company. PK and BC hold stock in Fresenius Medical Care. DM has been an employee of Fresenius Medical Care during the preparation of this paper. MJED, JPK, CJAMK, FMS, VM, YW, and JGR have no conflict of interest.

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

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Dekker, M.J.E., Usvyat, L.A., Konings, C.J.A.M. et al. Changes in pre-dialysis blood pressure variability in the first year of dialysis associate with mortality in European hemodialysis patients: a retrospective cohort study on behalf of the MONDO Initiative. J Hum Hypertens 35, 437–445 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


Quick links