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


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.

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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.

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.


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


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.

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Authors and Affiliations



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.

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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.

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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 (2023).

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