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.

  • Article
  • Published:

The association of sex differences in ambulatory blood pressure with cardiovascular events and mortality in dialysis patients

Journal of Human Hypertension (2024)Cite this article

Subjects

Abstract

Male patients with pre-dialysis chronic kidney disease (CKD) have worse ambulatory blood pressure (BP) control than females; this is associated with higher mortality. Male hemodialysis patients have higher ambulatory BP levels than females. This analysis aimed to investigate the association of sex differences in ambulatory BP with cardiovascular events and mortality in hemodialysis individuals. 129 male and 91 female hemodialysis patients with valid 48-h BP monitoring were followed for 53.4 ± 31.1 months. The primary endpoint was cardiovascular mortality; the secondary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, heart failure-hospitalization, coronary or peripheral revascularization. Cumulative freedom from the primary endpoint was lower for women (logrank-p = 0.032), while cumulative-freedom from the secondary endpoint did not differ significantly between-groups (logrank-p = 0.644). The crude risk for cardiovascular mortality was significantly higher in women (HR = 1.613, 95% CI [1.037, 2.509]). The crude risk for the combined endpoint was not different between the two groups (HR = 0.918, 95% CI [0.638, 1.320]). After adjusting for major risk factors (age, diabetes, dialysis vintage, coronary disease and hemoglobin) no significant differences in the risk for both the primary and the secondary endpoint were observed between women and men (primary: HR = 1.295 (95% CI [0.808, 2.078]), secondary: HR = 0.763 (95% CI [0.521, 1.118])). After additional adjustment for 44-h systolic BP the above relationships did not alter (primary: HR = 1.329 (95% CI [0.826, 2.137]), secondary: HR = 0.808 (95% CI [0.551, 1.184])). In conclusion, female hemodialysis patients have higher crude but similar adjusted cardiovascular mortality rates compared to male counterparts. In contrast to pre-dialysis CKD, the neutral relationship between gender and adverse cardiovascular outcomes in hemodialysis is not further affected by ambulatory BP.

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

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to full article PDF
Buy now

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

Fig. 1
Fig. 2

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. Carrero JJ, Hecking M, Chesnaye NC, Jager KJ. Sex and gender disparities in the epidemiology and outcomes of chronic kidney disease. Nat Rev Nephrol. 2018;14:151–64.

    Article  PubMed  Google Scholar 

  2. Florea A, Jacobs ET, Harris RB, Klimentidis YC, Thajudeen B, Kohler LN. Chronic kidney disease unawareness and determinants using 1999-2014 National Health and Nutrition Examination Survey Data. J Public Health. 2022;44:532–40.

    Article  Google Scholar 

  3. Ricardo AC, Yang W, Sha D, Appel LJ, Chen J, Krousel-Wood M, et al. Sex-Related Disparities in CKD Progression. J Am Soc Nephrol. 2019;30:137–46.

    Article  CAS  PubMed  Google Scholar 

  4. Minutolo R, Gabbai FB, Chiodini P, Provenzano M, Borrelli S, Garofalo C, et al. Sex Differences in the Progression of CKD Among Older Patients: Pooled Analysis of 4 Cohort Studies. Am J Kidney Dis. 2020;75:30–8.

    Article  CAS  PubMed  Google Scholar 

  5. Chesnaye NC, Dekker FW, Evans M, Caskey FJ, Torino C, Postorino M, et al. Renal function decline in older men and women with advanced chronic kidney disease-results from the EQUAL study. Nephrol Dial Transplant. 2021;36:1656–63.

    Article  CAS  PubMed  Google Scholar 

  6. Johansen KL, Chertow GM, Gilbertson DT, Herzog CA, Ishani A, Israni AK, et al. US Renal Data System 2021 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2022;79:A8–12.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Neugarten J, Acharya A, Silbiger SR. Effect of gender on the progression of nondiabetic renal disease: a meta-analysis. J Am Soc Nephrol. 2000;11:319–29.

    Article  PubMed  Google Scholar 

  8. Jafar TH, Schmid CH, Stark PC, Toto R, Remuzzi G, Ruggenenti P, et al. The rate of progression of renal disease may not be slower in women compared with men: a patient-level meta-analysis. Nephrol Dial Transplant. 2003;18:2047–53.

    Article  PubMed  Google Scholar 

  9. Balafa O, Fernandez-Fernandez B, Ortiz A, Dounousi E, Ekart R, Ferro CJ, et al. Sex disparities in mortality and cardiovascular outcomes in chronic kidney disease. Clin Kidney J. 2024;17:sfae044.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Nitsch D, Grams M, Sang Y, Black C, Cirillo M, Djurdjev O, et al. Associations of estimated glomerular filtration rate and albuminuria with mortality and renal failure by sex: a meta-analysis. BMJ. 2013;346:f324.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Carrero JJ, de Jager DJ, Verduijn M, Ravani P, De Meester J, Heaf JG, et al. Cardiovascular and noncardiovascular mortality among men and women starting dialysis. Clin J Am Soc Nephrol. 2011;6:1722–30.

    Article  PubMed  Google Scholar 

  12. Astley ME, Boenink R, Abd ElHafeez S, Trujillo-Alemán S, Arribas F, Åsberg A, et al. The ERA Registry Annual Report 2020: a summary. Clin Kidney J. 2023;16:1330–54.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Sarafidis P, Burnier M. Sex differences in the progression of kidney injury and risk of death in CKD patients: is different ambulatory blood pressure control the underlying cause? Nephrol Dial Transplant. 2021;36:1965–7.

    Article  PubMed  Google Scholar 

  14. Minutolo R, Gabbai FB, Agarwal R, Garofalo C, Borrelli S, Chiodini P, et al. Sex difference in ambulatory blood pressure control associates with risk of ESKD and death in CKD patients receiving stable nephrology care. Nephrol Dial Transplant. 2021;36:2000–7.

    Article  PubMed  Google Scholar 

  15. Sarafidis PA, Persu A, Agarwal R, Burnier M, de Leeuw P, Ferro C, et al. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). J Hypertens. 2017;35:657–76.

    Article  CAS  PubMed  Google Scholar 

  16. Theodorakopoulou MP, Karagiannidis AG, Alexandrou M-E, Polychronidou G, Karpetas A, Giannakoulas G, et al. Sex differences in ambulatory blood pressure levels, control and phenotypes of hypertension in hemodialysis patients. J Hypertens. 2022;40:1735–43.

    Article  CAS  PubMed  Google Scholar 

  17. Iatridi F, Theodorakopoulou MP, Karpetas A, Sgouropoulou V, Georgiou A, Karkamani E, et al. Association of Intradialytic Hypertension with Future Cardiovascular Events and Mortality in Hemodialysis Patients: Effects of Ambulatory Blood Pressure. Am J Nephrol. 2023;54:299–307.

    Article  CAS  PubMed  Google Scholar 

  18. Wei W, Tölle M, Zidek W, van der Giet M. Validation of the mobil-O-Graph: 24 h-blood pressure measurement device. Blood Press Monit. 2010;15:225–8.

    Article  PubMed  Google Scholar 

  19. Parati G, Stergiou G, O’Brien E, Asmar R, Beilin L, Bilo G, et al. European Society of Hypertension practice guidelines for ambulatory blood pressure monitoring. J Hypertens. 2014;32:1359–66.

    Article  CAS  PubMed  Google Scholar 

  20. Kontogiorgos I, Georgianos PI, Vaios V, Vareta G, Georgianou E, Karligkiotis A, et al. Gender-Related Differences in the Levels of Ambulatory BP and Intensity of Antihypertensive Treatment in Patients Undergoing Peritoneal Dialysis. Life. 2023;13:1140.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Korogiannou M, Sarafidis P, Theodorakopoulou MP, Alexandrou ME, Xagas E, Argyris A, et al. Sex differences in ambulatory blood pressure levels, control, and phenotypes of hypertension in kidney transplant recipients. J Hypertens. 2022;40:356–63.

    Article  CAS  PubMed  Google Scholar 

  22. Ramirez LA, Sullivan JC. Sex Differences in Hypertension: Where We Have Been and Where We Are Going. Am J Hypertens. 2018;31:1247–54.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Song J-J, Ma Z, Wang J, Chen L-X, Zhong J-C. Gender Differences in Hypertension. J Cardiovasc Transl Res. 2020;13:47–54.

    Article  PubMed  Google Scholar 

  24. Kalibala J, Pechère-Bertschi A, Desmeules J. Gender Differences in Cardiovascular Pharmacotherapy-the Example of Hypertension: A Mini Review. Front Pharmacol. 2020;11:564.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Mauvais-Jarvis F, Berthold HK, Campesi I, Carrero J-J, Dakal S, Franconi F, et al. Sex- and Gender-Based Pharmacological Response to Drugs. Pharmacol Rev. 2021;73:730–62.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Abad-Santos F, Novalbos J, Gálvez-Múgica M-A, Gallego-Sandín S, Almeida S, Vallée F, et al. Assessment of sex differences in pharmacokinetics and pharmacodynamics of amlodipine in a bioequivalence study. Pharmacol Res. 2005;51:445–52.

    Article  CAS  PubMed  Google Scholar 

  27. Cabaleiro T, Román M, Ochoa D, Talegón M, Prieto-Pérez R, Wojnicz A, et al. Evaluation of the relationship between sex, polymorphisms in CYP2C8 and CYP2C9, and pharmacokinetics of angiotensin receptor blockers. Drug Metab Dispos. 2013;41:224–9.

    Article  CAS  PubMed  Google Scholar 

  28. Chang H-J, Lin K-R, Lin M-T, Chang J-L. Associations Between Lifestyle Factors and Reduced Kidney Function in US Older Adults: NHANES 1999-2016. Int J Public Health. 2021;66:1603966.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study. J Am Coll Cardiol. 2020;76:2982–3021.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Kang SC, Jhee JH, Joo YS, Lee SM, Nam KH, Yun H-R, et al. Association of Reproductive Lifespan Duration and Chronic Kidney Disease in Postmenopausal Women. Mayo Clin Proc. 2020;95:2621–32.

    Article  CAS  PubMed  Google Scholar 

  31. Fernandez-Fernandez B, Mahillo I, Sanchez-Rodriguez J, Carriazo S, Sanz AB, Sanchez-Niño MD, et al. Gender, Albuminuria and Chronic Kidney Disease Progression in Treated Diabetic Kidney Disease. J Clin Med. 2020;9:1611.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Pisoni RL, Gillespie BW, Dickinson DM, Chen K, Kutner MH, Wolfe RA. The Dialysis Outcomes and Practice Patterns Study (DOPPS): design, data elements, and methodology. Am J Kidney Dis. 2004;44:7–15.

    Article  PubMed  Google Scholar 

  33. De La Mata NL, Rosales B, MacLeod G, Kelly PJ, Masson P, Morton RL, et al. Sex differences in mortality among binational cohort of people with chronic kidney disease: population based data linkage study. BMJ. 2021;375:e068247.

    Article  PubMed  Google Scholar 

  34. Ward LJ, Laucyte-Cibulskiene A, Hernandez L, Ripsweden J, GOING-FWD Collaborators, Stenvinkel P, et al. Coronary artery calcification and aortic valve calcification in patients with kidney failure: a sex-disaggregated study. Biol Sex Differ. 2023;14:48.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. DuPont JJ, Kenney RM, Patel AR, Jaffe IZ. Sex differences in mechanisms of arterial stiffness. Br J Pharmacol. 2019;176:4208–25.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. First Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Fotini Iatridi, Marieta P. Theodorakopoulou, Areti Georgiou, Artemios G. Karagiannidis, Nasra Haddad, Nikolaos Devrikis & Pantelis Sarafidis

  2. AIT Austrian Institute of Technology GmbH, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria

    Christopher C. Mayer

  3. First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Vasileios Kamperidis & Vasileios Anastasiou

  4. Therapeutiki Hemodialysis Unit, Thessaloniki, Greece

    Antonios Karpetas

Authors
  1. Fotini Iatridi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marieta P. Theodorakopoulou
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Areti Georgiou
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Artemios G. Karagiannidis
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nasra Haddad
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Nikolaos Devrikis
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Christopher C. Mayer
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Vasileios Kamperidis
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Vasileios Anastasiou
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Antonios Karpetas
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Pantelis Sarafidis
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceptualization: PS; Data curation: FI, MT, AG, AK, NH, ND, AK, CCM, VK and VA; Formal analysis: FI, MT, and CCM; Methodology: FI, MT and PS; Writing-original draft: FI, AG, MT and PS; Writing- review & editing: FI, PS; Supervision and mentorship: PS.

Corresponding author

Correspondence to Fotini Iatridi.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethics

The study protocol was obtained by the Ethics Committee of School of Medicine, Aristotle University of Thessaloniki; all evaluations were performed according to the Declaration of Helsinki (2013 Amendment).

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

Iatridi, F., Theodorakopoulou, M.P., Georgiou, A. et al. The association of sex differences in ambulatory blood pressure with cardiovascular events and mortality in dialysis patients. J Hum Hypertens (2024). https://doi.org/10.1038/s41371-024-00952-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1038/s41371-024-00952-z

Search

Advanced search

Quick links