Chapter - 8 BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA IN PATIENTS ON DIALYSIS

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1 Chapter - BLOOD PRESSURE CONTROL AND DYSLIPIDAEMIA IN PATIENTS ON DIALYSIS S. Prasad Meo Hooi Lai Seog Lee Wa Ti Suita Bavaada

2 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY SECTION.: BLOOD PRESSURE CONTROL ON DIALYSIS For the first time i the aalysis of data o blood pressure ad lipid profile i the Malaysia Dialysis ad Trasplat Registry (MDTR), this year s review will also aalyse mortality data i relatio to blood pressure ad lipid profile i dialysis patiets. I, the difficulty i achievig good cotrol of predialysis systolic blood pressure i haemodialysis patiets persisted, with oly % of haemodialysis patiets achievig systolic BP < mmhg (Table.). The mea ad media predialysis systolic blood pressure i haemodialysis patiets i was similar at a relatively high figure of. mmhg. Table.: Distributio of pre dialysis systolic blood pressure, HD patiets - patiets Mea SD % Patiets (mmhg) < -< -< -< Figure.: Cumulative distributio of pre dialysis systolic blood pressure, HD patiets - Cumulative distributio... Pre dialysis Systolic Blood Pressure (mmhg) I cotrast to haemodialysis patiets, predialysis systolic blood pressure was better cotrolled i peritoeal dialysis patiets i, with % of PD patiets havig a predialysis systolic BP < mmhg (Table..). The mea ad media predialysis systolic BP i PD patiets was also lower tha haemodialysis patiets at mmhg ad mmhg respectively. There was little discerable chage i the mea predialysis systolic blood pressure i PD patiets over the past years as illustrated i the data i Table...

3 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Table..: Distributio of pre dialysis systolic blood pressure, PD patiets - patiets Mea SD % Patiets (mmhg) < -< -< -< Figure..: Distributio of pre dialysis systolic blood pressure, PD patiets - Cumulative distributio... Pre dialysis Systolic Blood Pressure (mmhg) Predialysis diastolic blood pressure i haemodialysis patiets was better cotrolled tha predialysis systolic blood pressure i, with % of such patiets achievig predialysis diastolic BP < mmhg (Table.). The mea ad media predialysis diastolic blood pressure i haemodialysis patiets was satisfactory at. mmhg ad. mmhg respectively i. The mea predialysis diastolic blood pressure i haemodialysis patiets has decreased slightly from. mmhg i to. mmhg i. Table.: Distributio of pre dialysis diastolic blood pressure, HD patiets - patiets Mea SD % Patiets (mmhg) < -< -< -<

4 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Figure.: Cumulative distributio of pre dialysis diastolic blood pressure, HD patiets - Cumulative distributio... Pre dialysis Diastolic Blood Pressure (mmhg) I peritoeal dialysis patiets, the predialysis diastolic blood pressure was also well cotrolled i with % of these patiets achievig diastolic BP < mmhg (Table..). The mea ad media predialysis diastolic blood pressure i PD patiets was satisfactory at. mmhg ad. mmhg respectively i. There was a slight tred towards a lower mea predialysis diastolic blood pressure i PD patiets over the past years (. mmhg i versus. mmhg i ). Table..: Distributio of pre dialysis diastolic blood pressure, PD patiets - patiets Mea SD % Patiets (mmhg) < -< -< -< Figure..: Cumulative Distributio of pre dialysis diastolic blood pressure, PD patiets - Cumulative distributio... Pre dialysis Diastolic Blood Pressure (mmhg)

5 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Whe comparig data amog hemodialysis cetres i Malaysia, there remaied sigificat cetre variatio i media systolic blood pressure i haemodialysis patiets i (Figure..a). I, the differece betwee the HD cetres with the secod lowest (th percetile) ad secod highest media systolic blood pressure (th percetile) was. mmhg (Table..a). Figure..a will be more useful for idividual dialysis cetres to ascertai where their dialysis cetre stads i relatio to other cetres ad perhaps remedial actio ca be istituted if they were idetified as outlier cetres at the extreme ed of the variatio i media systolic blood pressure cotrol (Figure..a & b). Table..(a): systolic blood pressure amog HD patiets, HD cetres cetres Mi th Cetile th Cetile Figure..(a): Variatio i media systolic blood pressure amog HD patiets, HD cetres systolic blood pressure (lower quartile, upper quartile) Systolic blood pressure, mmhg Cetre

6 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Similarly for media diastolic blood pressure i haemodialysis patiets, there was also a wide cetre variatio amog haemodialysis cetres i Malaysia i (Figure..b). The differece betwee the HD cetres with the secod lowest (th percetile) ad secod highest (th percetile) media diastolic blood pressure was about. mmhg (Table..b). Table..(b): diastolic blood pressure amog HD patiets, HD cetres cetres Mi th Cetile th Cetile Figure..(b): Variatio i media diastolic blood pressure amog HD patiets, HD cetres diastolic blood pressure (lower quartile, upper quartile) Diastolic blood pressure, mmhg Cetre There was also a wide cetre variatio amogst haemodialysis cetres i i the proportio of patiets achievig BP / (Table & Figure..c). Table..(c): Proportio of HD patiets with pre dialysis blood pressure / mmhg, HD cetres cetres Mi th Cetile th Cetile...

7 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Figure..(c): Variatio i proportio of HD patiets with pre dialysis blood pressure / mmhg, HD % with pre dialysis blood pressure <=/ mmhg (lower quartile, upper quartile) % patiets, mmhg Cetre While the umber of PD cetres i Malaysia were sigificatly less tha the umber of haemodialysis cetres, there was still a sigificat cetre variatio i media systolic blood pressure i PD patiets i (Figure..a). The differece betwee the PD cetres with the secod lowest (th percetile) ad the secod highest media systolic blood pressure (th percetile) was. mmhg i (Table..a). Similarly there was also a sigificat cetre variatio i media diastolic blood pressure i PD patiets i (Table & Figure..b). Table..(a): systolic blood pressure amog PD patiets, PD cetres - cetres Mi th Cetile th Cetile Figure..(a): Variatio i media systolic blood pressure amog PD patiets, PD cetres systolic blood pressure (lower quartile, upper quartile) Systolic blood pressure, mmhg Cetre

8 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Table..(b): diastolic blood pressure amog PD patiets, PD cetres - cetres Mi th Cetile th Cetile Figure..(b): Variatio i media diastolic blood pressure amog PD patiets, PD cetres diastolic blood pressure (lower quartile, upper quartile) Diastolic blood pressure, mmhg Cetre Similar to haemodialysis cetres, there was also a wide variatio amogst PD cetres i the proportio of patiets achievig BP </ i (Table & Figure..c). Figure..c show that there were exemplary peritoeal dialysis cetres where more tha % of their patiets were able to achieve target blood pressure of less tha /. Table..(c): Proportio of PD patiets with pre dialysis blood pressure / mmhg, PD cetres - cetres Mi th Cetile th Cetile....

9 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Figure..(c): Variatio i proportio of PD patiets with pre dialysis blood pressure / mmhg, PD cetres % with pre dialysis blood pressure <=/ mmhg (lower quartile, upper quartile) % patiets, mmhg Cetre The ew data aalysig the correlatio of blood pressure profile ad death as well as cardiovascular death ad ischaemic heart disease i all dialysis patiets for the period to were detailed i Table..a. Dialysis patiets with low blood pressure (BP </) were at the highest risk of death compared to all other blood pressure categories. Dialysis patiets with highest blood pressure (BP >/) were the group with the secod highest risk of death. Hece there was a U shaped curve i the relatioship betwee blood pressure ad death i dialysis patiets as illustrated i Figure..a. Table..b details the hazard ratio for death i each of the blood pressure categories, utilisig the BP category of </ as the referece stadard. It was oted that the hazard ratio of all other categories were less tha compared to the referece stadard emphasisig the highest risk of death associated with dialysis patiets with low blood pressure. Table..(a): Correlatio of blood pressure profile ad death, cardiovascular death ad ischaemic heart disease, dialysis patiets - SBP< ad DBP< (I) Me Death CVD/IHD Wome Death CVD/IHD % SBP - ad DBP - (II) SBP - ad DBP - (III) % SBP - ad DBP - (IV) % % % Death Death Figure..(a): Relatioship betwee blood pressure ad death i dialysis patiets - I % SBP>= ad DBP>= (V) II Death (Male) % Death (Male) III BP Group IV V Death (Female) % Death (Female)

10 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Table..(b): Hazard ratio for death i each of the blood pressure categories, - SBP< ad DBP< (Ref.) SBP - ad DBP - SBP - ad DBP - SBP - ad DBP - SBP >= ad DBP>=.. (. ;.) <.. (. ;.) <.. (. ;.) <.. (. ;.)... (. ;.) <.. (. ;.) <.. (. ;.) <.. ( ;.) <. Me Hazard ratio % CI p-value Wome Hazard ratio % CI p-value SECTION.: DYSLIPIDAEMIA IN DIALYSIS PATIENTS The optimal target for cholesterol ad triglyceride levels i dialysis patiets were still ope to debate. However there was o doubt that cardiovascular disease was the major cause of death i dialysis patiets ad correctio of reversible risk factors for CVD should be attempted i most dialysis patiets. I, it was comfortig to kow that % of haemodialysis patiets had total cholesterol <. mmol/l. This was a higher figure tha years ago (% i ) (Table..). The mea ad media serum cholesterol levels i HD patiets i were.mmol/l ad.mmol/l respectively. Table..: Distributio of serum cholesterol, HD patiets - patiets Mea SD % Patiets (mmol/l) <..-<..-< Figure..: Cumulative distributio of cholesterol, HD patiets - Cumulative distributio... Serum cholesterol (mmol/l).

11 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY However total cholesterol levels i peritoeal dialysis patiets were less optimally cotrolled i compariso with haemodialysis patiets, with oly % of PD patiets achievig total cholesterol. mmol/l i (Table & Figure..). The mea ad media serum cholesterol levels i PD patiets i were. mmol/l ad. mmol/l respectively. These figures were slightly lower tha figures (mea. mmol/l ad media. mmol/l). Table..: Distributio of serum cholesterol, PD patiets - patiets Mea SD % Patiets (mmol/l) <..-<..-<.. Figure..: Cumulative distributio of cholesterol (mmol/l), PD patiets - Cumulative distributio... Serum cholesterol (mmol/l) With regards to triglyceride levels, about ¾ of haemodialysis patiets have a triglyceride level of <. mmol/l (Table..). The mea ad media serum triglyceride i haemodialysis patiets i were. mmol/l ad. mmol/l respectively. Table..: Distributio of serum triglyceride, HD patiets - patiets Mea SD % Patiets (mmol/l) <..-<..-<

12 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Figure..: Cumulative distributio of serum triglyceride, HD patiets - Cumulative distributio... Serum triglyceride (mmol/l) Peritoeal dialysis patiets also have a similar level of triglyceride cotrol with % of PD patiets havig triglyceride level <. mmol/l (Table..). The mea ad media serum triglyceride i PD patiets have decreased slightly over the past years from. mmol/l ad mmol/l i to. mmol/l ad. mmol/l i respectively. Table..: Distributio of serum triglyceride, PD patiets - patiets Mea SD Figure..: Cumulative distributio of serum triglyceride, PD patiets - Cumulative distributio... Serum triglyceride (mmol/l) <. % Patiets (mmol/l).-<..-<..

13 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY There was some cetre variatio i media serum cholesterol levels ad proportio of HD patiets with serum cholesterol <.mmol/l i HD ceters i (Table..a & b). There were some exemplary dialysis cetres who reported more tha % of their patiets achievig serum cholesterol <. mmol/l i. Table..(a): serum cholesterol level amog HD patiets, HD cetres - cetres Mi th Cetile th Cetile Figure..(a): Variatio i media serum cholesterol level amog HD patiets, HD cetres serum cholesterol (lower quartile, upper quartile) Serum cholesterol, mmol/l..... Cetre Table..(b): Proportio of HD patiets with serum cholesterol <.mmol/l, HD cetres - cetres Mi th Cetile th Cetile.

14 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Figure..(b): Variatio i proportio of patiets with serum cholesterol <. mmol/l, HD cetres % with serum cholesterol <. mmol/l (lower % CI, upper % CI) % patiets Cetre There appears to be less cetre variatio i media serum triglyceride levels amogst haemodialysis cetres with the differece betwee the secod lowest (th percetile) ad secod highest media triglyceride level (th percetile) beig oly. mmol/l (Table & Figure..c). There appears to be more cetre variatio i the proportio of patiets with serum triglyceride <. mmol/l i haemodialysis cetres i (Table & Figure..d). Table..(c): serum triglyceride level amog HD patiets, HD cetres - cetres Mi th Cetile th Cetile Figure..(c): Variatio i media serum triglyceride level amog HD patiets, HD ceters serum triglyceride (lower quartile, upper quartile) serum triglyceride, mmol/l Cetre

15 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Table..(d): Proportio of HD patiets with serum triglyceride <. mmol/l, HD cetres cetres Mi th Cetile th Cetile.. Figure..(d): Variatio i proportio of patiets with serum triglyceride <.mmol/l, HD ceters % with serum triglyceride <. mmol/l (lower % CI, upper % CI) % patiets Cetre There was some cetre variatio i media cholesterol levels amog PD patiets i with the differece betwee the secod lowest (th percetile) ad secod highest (th percetile) media cholesterol level beig mmol/l (Table & Figure..a). There was also cetre variatio i proportio of PD patiets with serum cholesterol <. mmol/l as illustrated i Figure..b. Table..(a): serum cholesterol level amog PD patiets, PD cetres - cetres Mi th Cetile th Cetile

16 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Figure..(a): Variatio i media serum cholesterol level amog PD patiets, PD cetres serum cholesterol (lower quartile, upper quartile). Serum cholesterol, mmol/l..... Cetre Table..(b): Proportio of PD patiets with serum cholesterol <. mmol/l, PD cetres - cetres Mi th Cetile th Cetile.. Figure..(b): Variatio i proportio of patiets with serum cholesterol <. mmol/l, PD cetres % with serum cholesterol <. mmol/l (lower % CI, upper % CI) % patiets Cetre

17 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY As i previous years, there was oly mild cetre variatio i media triglyceride levels amog PD cetres, except for outlier cetre with media serum triglyceride >.mmol/l (Figure..c). There was some cetre variatio amogst PD cetres i the proportio of patiets with serum triglyceride levels <. mmol/l. (Table & Figure..d). Table..(c): serum triglyceride level amog PD patiets, PD cetres - cetres Mi th Cetile th Cetile Figure..(c): Variatio i media serum triglyceride level amog PD patiets, PD cetres serum triglyceride (lower quartile, upper quartile) serum triglyceride, mmol/l... Cetre Table..(d): Proportio of PD patiets with serum triglyceride <. mmol/l, PD cetres - cetres Mi th Cetile th Cetile....

18 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Figure..(d): Variatio i proportio of patiets with serum triglyceride <. mmol/l, PD cetres % with serum triglyceride <. mmol/l (lower % CI, upper % CI) % patiets Cetre Table..a was a ew table correlatig the relatioship of differet categories of cholesterol levels with death i dialysis patiets for the period to. The highest rate of death occurs i dialysis patiets with low total cholesterol levels (<. mmol/l). This was i cotrast to the geeral populatio ad may reflect umeasured utritioal issues. Dialysis patiets who were malourished may form a sigificat part of this cohort of low cholesterol levels ad we do kow that malourished dialysis patiets were at a higher risk of death. The lowest risk of death were amog dialysis patiets with total cholesterol levels betwee. mmol/l ad. mmol/l. Figure..a illustrate the U curve relatioship betwee serum cholesterol categories ad death. Table..b details the hazard ratio for death i each of the total cholesterol categories, utilisig the total cholesterol category of <. mmol/l as the referece stadard. It was oted that the hazard ratio of all other categories were less tha compared to the referece stadard emphasisig the highest risk of death associated with dialysis patiets with low cholesterol levels. Table..(a): Relatioship of differet categories of cholesterol levels with death, dialysis patiets - <. mmol/l Me Death CVD/IHD Wome Death CVD/IHD.-<. mmol/l.-<. mmol/l % % % % Figure..(a): Relatioship betwee serum cholesterol categories ad death, dialysis patiets - % Death Death <. >=. mmol/l.-<..-<. Serum Cholesterol (mmol/l) Death (Male) % Death (Male) >=. Death (Female) % Death (Female)

19 ST REPORT OF THE MALAYSIAN DIALYSIS AND TRANSPLANT REGISTRY Table..(b): Hazard ratio for death i each of the total cholesterol categories, dialysis patiet - <.mmol/l (Ref) Me Hazard ratio % CI p-value Wome Hazard ratio % CI p-value.-<. mmol/l.-<. mmol/l >=. mmol/l.. (. ;.) <.. (. ;.) <.. (. ;.)... (. ;.) <.. (. ;.) <.. (. ;.) <. Recommedatio: Malaysia Dialysis ad Trasplat Registry may cosider to high light i its executive summary to the cetre for those cetres which were either i the top or bottom % of variatio i importat parameters such as BP, lipid profile, Kt/V, mortality data, etc. It will be iterestig to documet the exemplary ati-hypertesive practices ad lipid lowerig strategies employed i some of the model haemodialysis cetres who reported high proportio of their patiets achieved good BP ad lipid cotrol ad the dissemiate such best practice to the less well performig cetres.

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