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Exploring the paradoxical relationship of hypertension with mortality in chronic hemodialysis

Hypertension is seen in 85% of patients on hemodialysis (HD) in the United States. Although it is amply clear that high blood pressure (BP) has a continuous, graded, and etiologically significant relationship with cardiovascular outcomes in the general population, studies in HD patients have found an inverse relationship between high BP and outcomes. Thus, those patients with high BP have a lower mortality compared to those with low BP. It is intellectually troublesome to find such an association because high BP, which was such an important risk factor for cardiovascular disease before onset of dialysis suddenly, becomes a protective factor. In patients with chronic kidney disease who are not yet on HD, we strive to lower BP more aggressively than what we target those with uncomplicated essential hypertension. If these observations—‘‘reverse epidemiology’’ or ‘‘risk factor paradox’’—are etiologically significant, should we be complacent about treating high BP in HD? The objective of this analysis is to review the data to explain these apparently troublesome observations. POOR ASSESSMENT OF BP: REGRESSION DILUTION BIAS