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BackgroundThe excess pressure integral (XSPI), derived from analysis of the arterial pressure curve, may be a significant predictor of cardiovascular events in high‐risk patients. We comprehensively investigated the prognostic value of XSPI for predicting long‐term mortality in end‐stage renal disease patients undergoing regular hemodialysis.Methods and ResultsA total of 267 uremic patients (50.2% female; mean age 54.2±14.9 years) receiving regular hemodialysis for more than 6 months were enrolled. Cardiovascular parameters were obtained by echocardiography and applanation tonometry. Calibrated carotid arterial pressure waveforms were analyzed according to the wave‐transmission and reservoir‐wave theories. Multivariable Cox proportional hazard models were constructed to account for age, sex, diabetes mellitus, albumin, body mass index, and hemodialysis treatment adequacy. Incremental utility of the parameters to risk stratification was assessed by net reclassification improvement. During a median follow‐up of 15.3 years, 124 deaths (46.4%) incurred. Baseline XSPI was significantly predictive of all‐cause (hazard ratio per 1 SD 1.4, 95% confidence interval 1.15‐1.70, P=0.0006) and cardiovascular mortalities (1.47, 1.18‐1.84, P=0.0006) after accounting for the covariates. The addition of XSPI to the base prognostic model significantly improved prediction of both all‐cause mortality (net reclassification improvement=0.1549, P=0.0012) and cardiovascular mortality (net reclassification improvement=0.1535, P=0.0033). XSPI was superior to carotid‐pulse wave velocity, forward and backward wave amplitudes, and left ventricular ejection fraction in consideration of overall independent and incremental prognostics values.ConclusionsIn end‐stage renal disease patients undergoing regular hemodialysis, XSPI was significantly predictive of long‐term mortality and demonstrated an incremental value to conventional prognostic factors.

Increased short-term blood pressure (BP) variability is associated with adverse cardiovascular outcomes in patients with hypertension. The present study investigated the long-term prognostic significance of the short-term blood pressure variability in patients on hemodialysis. A total of 149 patients (53.0% male; mean age: 54.5±15.1 years) receiving regular hemodialysis for >6 months were enrolled. They completed a 44-hour (excluding the hemodialysis session) ambulatory BP monitoring and comprehensive hemodynamic assessments, including carotid-femoral pulse wave velocity and pressure waveform decomposition (forward and backward wave amplitude). Blood pressure variability parameters, including average real variability (ARV) of systolic BP, diastolic BP, and pulse pressure (ARVp) during daytime, nighttime, and overall 44 hours were calculated. During a median follow-up of 14 years, 78 deaths (52.4%) were confirmed. In multivariable Cox regression analysis, none of the ambulatory BP parameters were predictive of mortality. In contrast, nighttime ARVp was consistently and significantly associated with all-cause mortality in multivariable Cox models adjusting for age, sex, albumin, hemodialysis treatment adequacy, and 44-hour systolic BP (continuous variable analysis, per 1-SD, hazard ratio=1.348; 95% CI, 1.029–1.767; categorical variable analysis, ≥8.5 versus <8.5 mm Hg; hazard ratio=1.825; 95% CI, 1.074–3.103). Forward wave amplitude and 44-hour systolic BP were identified as the 2 most important determinants of nighttime ARVp. Addition of nighttime ARVp to the base model significantly improved prediction of all-cause mortality (Net reclassification improvement =0.198; P =0.0012). In hemodialysis patients, increased short-term nighttime pulse pressure variability but not ambulatory BP levels were significantly predictive of long-term all-cause mortality.

Background: The prognostic significance of the eGFR calculated by either the four-level Race Chronic Kidney Disease-Epidemiology Collaboration study equation (CKD-EPI4R) or the Chinese-modified Modification of Diet in Renal Disease equation (cMDRD) has not been compared in Asian populations with acute heart failure (AHF). Methods and Results: A total of 3,044 patients hospitalized for AHF were enrolled. The National Death Registry was linked to identify deaths within a 5-year follow-up. Net reclassification improvement (NRI) was calculated to compare the prognostic value of either eGFR equation. During a median follow-up of 23.3 months, 1,424 (47%) patients died. Both eGFRcMDRD and eGFRCKD-EPI4R were independently predictive of death in the total study population (hazard ratio and 95% confidence intervals per 1-SD: 0.76, 0.71-0.81 and 0.74, 0.70-0.79, respectively), and in the subgroups of either reduced (HFrEF) or preserved (HFpEF) ejection fraction, after accounting for important confounders. With reference to eGFRcMDRD, eGFRCKD-EPI4R may improve the NRI by 2.0% (0.8-3.2%) for the prediction of death. The prognostic value of the CKD stages categorized by eGFRCKD-EPI4R significantly outperformed eGFRcMDRD with a categorical NRI of 9.5% (4.7-14.3%) in the total study population, 11.5% in HFrEF, and 8.3% in HFpEF. Conclusions: Both eGFRcMDRD and eGFRCKD-EPI4R were independently associated with long-term survival in patients with AHF. However, the CKD stages derived from eGFRCKD-EPI4R improved the risk stratification of death, compared with eGFRcMDRD.