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The temporal association between percutaneous coronary intervention and intradialytic hypotension in hemodialysis patients

Renal Replacement Therapy volume 11, Article number: 17 (2025) Cite this article

Abstract

Background

Cardiovascular disease is a leading cause of mortality in end-stage kidney disease, with ischemic heart disease being prevalent. Intradialytic hypotension (IDH) is a common complication during hemodialysis (HD), with poorly understood associations with coronary artery disease and the impact of percutaneous coronary intervention (PCI). This study examines the temporal effects of PCI on IDH in dialysis patients.

Methods

Patients undergoing HD at National Cheng Kung University Hospital from 1 January 2016 to 30 November 2022 were included. IDH was defined as a systolic blood pressure below 90 mmHg. HD sessions for 180 days before and after PCI were analyzed using generalized estimating equations. We calculated odds ratios (ORs) for IDH risk at various intervals relative to PCI, adjusting for demographics, comorbidities, dialysis parameters, antihypertensive medication use, and laboratory data.

Results

In total, 39 patients underwent 51 PCI procedures, with 6938 sessions analyzed. Within 90 days post-PCI, IDH risk decreased significantly (OR 0.667; 95% CI 0.465–0.957; P = 0.028) compared with baseline (90 days pre-PCI), but no statistically significant reduction within 91–180 days. Patients with diabetes exhibited a pronounced reduction in IDH risk within 90 days (OR 0.545; 95% CI 0.378–0.786; P = 0.001) and in 180 days (OR 0.551; 95% CI 0.379–0.799; P = 0.002). Monthly trends indicated a gradual increase in IDH risk pre-PCI, peaking 2 months prior to PCI, followed by a sustained decline during the first 3 months post-PCI.

Conclusions

PCI is associated with a reduction in the risk of IDH, particularly in patients with diabetes, within the first 3 months post-intervention. This study highlights the temporal benefits of PCI in managing IDH, especially in high-risk populations, such as dialysis patients with DM. Further investigation into PCI benefits is warranted.

Introduction

Cardiovascular disease is the major cause of death in patients with end-stage kidney disease (ESKD) [1, 2]. The incidence of ischemic heart disease is approximately 10 times higher in hemodialysis (HD) patients than in the general population [3]. Coronary revascularization, recommended for treating ischemic cardiomyopathy and acute coronary syndrome [4], restores blood flow to the under-perfused myocardium, enhancing left ventricular systolic function. This improvement in ejection fraction can significantly reduce mortality and hospitalization rates [5, 6]. Diabetes mellitus (DM), which is the most common cause of ESKD, is often associated with multivessel disease. Although coronary revascularization in patients with DM will improve symptoms, especially angina, previous studies have not shown a significant survival benefit [7, 8].

Intradialytic hypotension (IDH) is a common complication among patients with ESKD, with a prevalence rate ranging from 8% to 40% in various studies [9,10,11]. It is associated with factors such as ultrafiltration (UF), cardiac output, and autonomic dysfunction. Patients who frequently experience IDH have a higher risk of heart failure, myocardial infarction, higher mortality rate, and poorer quality of life [12,13,14]. Coronary artery calcification is considered a predictor for IDH [15, 16]. Though some studies have shown that percutaneous coronary intervention (PCI) can improve heart function, and decrease cardiac and all-cause mortality, in dialysis patients, especially in those who underwent complete revascularization [17, 18], a recent randomized controlled trial showed no benefit in reducing mortality and cardiovascular events in advanced chronic kidney disease, including dialysis patients, with stable coronary artery disease (CAD) [19]. Moreover, the impact of PCI on IDH frequency, a factor closely linked to patient quality of life, remains unclear. To address this gap, we conducted a retrospective observational study to explore the impact of PCI on IDH, providing insights to enhance clinical decision-making and personalize care for high-risk patients.

Methods

Study design

This observational cohort study investigated the association between PCI and IDH. It was conducted at the HD center of National Cheng Kung University Hospital, a tertiary teaching hospital in Tainan, Taiwan. The study period was between 1 January 2016 and 30 November 2022. A total of 230 patients who underwent HD were included in the study. Written informed consent was obtained from all patients (Fig. 1). The study was approved by the Institutional Review Board of National Cheng Kung University Hospital (A-ER-110-327) and adhered to the principles of the Declaration of Helsinki.

Fig. 1
figure 1

Patient enrollment and prevalence of IDH. HD hemodialysis, PCI percutaneous coronary intervention, IDH intradialytic hypotension

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Clinical covariates

Baseline characteristics were collected, including age, sex, and HD vintage (the duration a patient has been receiving HD). Comorbidities such as DM and hypertension (HTN) were recorded, along with the use of antihypertensive agents, including angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), beta blockers, alpha blockers, calcium channel blockers (CCB), vasodilators, and nitrates. We also collected laboratory data, including hemoglobin and albumin levels, which were related to IDH [20, 21].

PCI

PCI related data were collected by reviewing medical charts, coronary artery angiography reports, and diagnoses made by cardiologists at National Cheng Kung University Hospital. The date of each angiography procedure was documented. Patients were excluded if their available HD data did not include both the period before and after the PCI. We analyzed HD data within 180 days before and after PCI. To prevent duplicate data, only procedures with an interval of more than 1 year between them were included in the analysis for the same individual.

HD records

The study collected HD records, including various parameters, such as HD vintage (months), blood pressure (mmHg), pre-HD body weight (kg), dry weight (kg), UF weight (kg), blood flow (mL/min), dialysate flow (mL/min), dialysate average temperature (°C), and dialysate calcium (mEq/L).

The determination of IDH

IDH was identified using the nadir criteria (Nadir90), where systolic blood pressure (SBP) dropped below 90 mmHg during HD. According to current research, this definition shows the strongest correlation with mortality [22]. Blood pressure measurements were obtained before the initiation of HD, every 60 min throughout the session, and in instances of clinical events, ensuring a minimum collection of five records per 4 h session. Each session was then categorized as either IDH or non-IDH [17].

Statistical analysis

Baseline patient characteristics and HD settings were presented as mean ± standard deviation for normally distributed continuous variables, or median with interquartile range for non-normally distributed continuous variables. Numbers and percentages were used for categorical variables. Differences in continuous variables between groups were analyzed using t-tests, while chi-squared tests were employed for categorical variables. Characteristics of HD sessions before and after PCI were compared using P-values and standardized differences—a measure that is not sensitive to sample size. A P-value less than 0.05 and a standardized difference greater than 0.1 were considered indicators of statistical significance [21].

We collected HD records before and after the date of PCI, which was defined as the index date. The risk of IDH was assessed using binary logistic regression. To account for the intercorrelation among HD sessions of the same patient, we utilized a generalized estimating equation method with a first-order autoregressive (AR-1) working correlation matrix. Our data were modeled using a binomial distribution with a logit link function. This modeling approach allowed us to calculate the log odds of an IDH event occurring in association with our variables of interest.

We used the 90 days before PCI (−90 to 0 days) as the baseline for assessing the risk of IDH. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to estimate the risk of IDH following PCI compared with the risk during the baseline period. The choice of 90-day intervals for statistical analysis is based on clinical evidence suggesting that significant improvements in cardiovascular function with left ventricular remodeling often occur within this timeframe after PCI, and further improvements were also observed up to 6 months [24, 25].

To account for potential confounding factors, four models were developed. Model 1 included demographic and clinical variables such as age, sex, HTN, and HD vintage (in months). Model 2 added HD-specific variables, including pre-HD SBP, UF, blood flow rate, dialysate calcium concentration, dialysate flow rate, and dialysate temperature to the variables in model 1. Model 3 further expanded on model 2 by incorporating the total number of antihypertensive medication categories used. Finally, model 4 built upon model 3 by incorporating laboratory data, specifically serum albumin and hemoglobin levels, to provide a more comprehensive analysis.

To evaluate whether the impact of PCI on IDH risk changes over time, the 90 days preceding PCI were designated as the baseline period. The incidence of IDH during the periods 0–90 days, 91–180 days, and 0–180 days after PCI, was compared with this baseline to assess changes in IDH risk post-PCI.

We also segmented the 360-day observation period into 12 30-day segments and compared the risk of each segment with the first 30 days (from 180 to 151 days pre-PCI) to show the periprocedural risk of IDH.

Results

Characteristics of HD sessions

A total of 230 patients were analyzed, including 58 patients who underwent PCI. Among these, 39 patients had HD data available both before and after PCI, all occurring after 1 January 2016, accounting for 51 PCI procedures (Fig. 1). Most procedures were performed electively, owing to stable angina or findings from diagnostic imaging, such as positive results on thallium scans or significant coronary calcification on cardiac computed tomography. Only six procedures were conducted for acute coronary syndromes, including four for non-ST elevation myocardial infarction and two for unstable angina. The analysis included 6938 HD sessions, with 3366 sessions before PCI and 3572 sessions after PCI. The overall incidence of IDH across all sessions was 10.4%, with a pre-PCI incidence of 11.1% and a post-PCI incidence of 9.8%. When stratified into 90-day intervals, the incidence was 9.8% from −180 to −90 days pre-PCI, 12.4% from −90 to 0 days pre-PCI, 8.9% from 0 to 90 days post-PCI, and 10.7% from 90 to 180 days post-PCI. A comparison of pre- and post-PCI patient demographics, HD settings, and antihypertensive medication usage (Table 1; Supplementary Table S1) showed no significant differences in sex, DM, HTN, UF, and dialysate calcium concentrations. Statistical analysis revealed a reduction in pre-HD SBP from 149 to 143 mmHg post-PCI and a minimal change in diastolic blood pressure from 74 to 72 mmHg. In addition, post-PCI, the use of ACEI/ARB and beta blockers increased significantly (Table 1).

Table 1 Characteristic of HD sessions before and after PCI
Full size table

Risk of IDH after PCI

When comparing IDH risk across different time frames with baseline, 90 days before PCI, a significant reduction in IDH risk was observed in the 90 days following PCI (0–90 days), as shown in the fully adjusted model (OR 0.667; 95% CI 0.465–0.957; P = 0.028) (Table 2). A significant reduction in IDH risk was observed in the 180 days following PCI (0–180 days) (OR 0.677; 95% CI 0.476–0.962; P = 0.030). Also seen in the 91–180 day period (OR 0.698; 95% CI 0.433–1.123; P = 0.138), indicating a trend toward reduced risk, but without statistical significance (Table 2).

Table 2 Univariate and multivariable logistic regression with generalized estimating equation methods for risk of IDH before and after PCI in different adjusted models
Full size table

Patients with and without DM

We analyzed the interactions between baseline comorbidities, specifically DM and HTN, and the effect of PCI on IDH (Supplementary Table S2). A significant interaction was observed for DM, with a P-value for the interaction of 0.001 and 0.006 when comparing 0–90 days and 0–180 days with baseline, respectively. In patients with DM, the risk of IDH after PCI was reduced during these time frames; specifically, the ORs were 0.545 (95% CI 0.378–0.786, P = 0.001) within 0–90 days post-PCI and 0.551 (95% CI 0.379–0.799, P = 0.002) within 0–180 days post-PCI in the adjusted model (Table 3).

Table 3 Logistic regression with generalized estimating equation methods for risk of IDH before and after PCI in patients with and without DM
Full size table

Risk of IDH varies over time

We compared the risk of IDH in consecutive 30-day intervals using the first 30 days (180–151 days pre-PCI) as a reference. The risk of IDH gradually increased before PCI and then decreased in the first 3 months after PCI. The highest risk is at about 2 months before PCI, with an OR of around 1.728 (95% CI 0.973–3.069), while the lowest risk is at the third month after PCI, with an OR of around 0.826 (95% CI 0.432–1.580). However, during the fourth to sixth months post-PCI, the risk of IDH slightly increased again (Fig. 2).

Fig. 2
figure 2

The OR of IDH peri-PCI. OR odds ratio, CI confidence interval, PCI percutaneous coronary intervention

Full size image

Discussion

This study analyzed 6938 sessions to explore the connection between IDH and CAD, as well as to assess the influence of PCI on IDH incidence. The results revealed a notable reduction in the risk of IDH within 3 months immediately after PCI, with an OR of 0.667, after adjusting for variables such as comorbidities and HD-related factors (e.g., pre-HD blood pressure, fluid removal volume, blood and dialysate flow rates, temperature, and dialysate calcium concentration). Notably, the association between PCI and a reduced risk of IDH was more evident in patients with diabetes, with ORs of 0.545 and 0.551, at 90 days and 180 days post PCI, compared with 90 days before PCI, respectively. These findings suggest that PCI may be associated with a temporary reduction in IDH risk, particularly in the initial months following the intervention.

Although initial risk of IDH decreased, there was no reduction in IDH risk between 91 and 180 days post-PCI in our cohort. Among the 39 patients, 10 (26.3%) were found to have in-stent restenosis on coronary angiography more than 180 days after their initial PCI. Studies suggest that dialysis patients face a higher risk of restenosis within the first year post-procedure [26,27,28] While our study cannot establish a direct causal relationship, early restenosis and diffuse CAD may contribute to the lack of IDH risk reduction during 91–180 days post-PCI [24]. This observation highlights the need for future studies to explore the effects of restenosis on long-term hemodynamic outcomes in this population.

No previous study has examined the longer-term temporal relationship between cardiac catheterization and IDH risk. Prior research has primarily focused on the immediate risk of IDH within the first day following cardiac procedures [29]. Our analysis revealed that the monthly risk of IDH increased gradually before intervention, particularly in the 3 months prior to PCI. This trend suggests that coronary narrowing, likely due to plaque accumulation, may already adversely affect heart function and hemodynamic stability during HD sessions before a clinical diagnosis of acute coronary syndrome or stable angina is made. IDH itself may also increase the risk of acute myocardial infarction [12]. Understanding these pre-PCI dynamics could inform earlier and possibly preventive interventions for patients at risk of IDH. This insight could be used to refine machine learning models for the prediction of IDH, and to help clinicians improve patient outcomes, ultimately enhancing patients’ quality of life, in the future.

Our study observed a correlation between PCI and a decreased risk of IDH. This effect was particularly pronounced in patients with DM, a group more likely to present with multivessel disease. The survival benefit of coronary intervention, compared with medical treatment alone, in dialysis patients is controversial. A recent study by Yasuda et al. focused on dialysis patients and demonstrated better cardiac survival in those who underwent PCI compared with those who received medication alone, particularly in individuals with multivessel disease [17]. However, some past studies, including the BARI-2D study, COURAGE trial, and ISCHEMIC trial, did not show significant improvements in overall mortality or major cardiovascular events with revascularization in patients with stable coronary artery disease [30,31,32]. Similarly, the ISCHEMIA-CKD trial, a randomized controlled study focusing on patients with advanced chronic kidney disease, found that an initial invasive approach combined with medical therapy did not provide additional benefits in mortality and cardiovascular events over a conservative strategy for managing stable CAD. Subgroup analyses of dialysis patients within this study also yielded consistent results [19]. Our findings may align with the results reported by Yasuda et al., suggesting that patients with complex coronary pathologies could derive greater benefits from PCI [17]. This highlights the potential value of PCI in selected dialysis patient populations, particularly those with multivessel disease or comorbid diabetes.

Patients with diabetes and CAD often have more diffuse and extensive coronary artery narrowing [33]. In our study, the proportion of patients with multivessel disease was significantly higher among patients with diabetes (92.6%, 25/27) compared with patients without diabetes (25%, 3/12). Besides, most patients with multivessel disease underwent stent placement, with 94.9% (37/39) of procedures involving stent implantation. The remaining 5.1% (2/39) were managed with balloon angioplasty for in-stent restenosis, without stent placement. Revascularization improves overall cardiac blood flow distribution, which is crucial for patients with diabetes undergoing HD [34, 35]. Because these patients often have more severe baseline CAD, they may experience a greater improvement in myocardial contractility—and thus a larger reduction in IDH risk—once blood flow is restored. However, the exact mechanisms and the long-term impact on low blood pressure during HD require further research and follow-up.

Our study has some limitations. First, it is a single-center retrospective observational study with a limited sample size. However, to mitigate this limitation, we collected robust data on IDH sessions before and after PCI, including detailed variables that may contribute to IDH, such as UF, dialysate temperature, dialysate calcium, HD vintage, and antihypertensive and heart failure medications. Second, some patients did not undergo PCI owing to personal reasons, which may introduce selection bias. To address this, we included both living and deceased patients from our HD center, thereby reducing potential selection and survivorship biases. Third, there was no formal cardiac echocardiography performed before and after PCI to confirm the mechanism of improvement, indicating a need for further study. Fourth, the use of saline or vasopressors might affect blood pressure meeting the IDH definition. However, this impact is likely minimal owing to consistent care protocols, similar saline volumes, and no significant difference in prescribed midodrine doses. As this was a retrospective study, detailed timing of these interventions was not available. Despite these limitations, our study is the first to provide evidence that PCI may be associated with a decreased risk of IDH in dialysis patients, particularly those with DM, highlighting the need for further evaluation of the risks and benefits of PCI in this population.

Conclusions

PCI significantly reduces IDH risk in the short term, particularly 3 months post-intervention, with pronounced benefits in patients with diabetes. This emphasizes the importance of timely PCI in IDH management, especially in individuals with diabetes, warranting further investigation into the temporal dimension of PCI benefits.

Availability of data and materials

Data sharing is beyond the scope of the permissions granted by the patients’ informed consent and the Institutional Review Board.

Abbreviations

ACEI:

Angiotensin-converting enzyme inhibitors

ARB:

Angiotensin II receptor blockers

CAD:

Coronary artery disease

CCB:

Calcium channel blockers

CI:

Confidence interval

DM:

Diabetes mellitus

ESKD:

End-stage kidney disease

HD:

Hemodialysis

HTN:

Hypertension

IDH:

Intradialytic hypotension

OR:

Odds ratio

PCI:

Percutaneous coronary intervention

SBP:

Systolic blood pressure

UF:

Ultrafiltration

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Acknowledgements

We extend our gratitude to the physicians in the Department of Nephrology for their invaluable assistance in data collection. This research was partially supported by the Higher Education Sprout Project from the Ministry of Education, allocated to the Headquarters of University Advancement at National Cheng Kung University (NCKU).

Funding

This study was funded by National Cheng Kung University grants (D112-F2523). The funders did not influence the study design, data analysis, interpretation, or manuscript approval.

Author information

Authors and Affiliations

  1. Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Tzu-Shan Huang, Wei-Ren Lin, Junne-Ming Sung, Ming-Cheng Wang, Chin-Chung Tseng & Kuan-Hung Liu

  2. Institute of Data Science, National Cheng Kung University, Tainan, Taiwan

    Jian-An Wang

  3. Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital Douliu Branch, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Yu-Huan Chiu

  4. Division of Nephrology, Kuo General Hospital, Tainan, Taiwan

    Zheng-Zhe Wu

  5. Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Po-Wei Chen

  6. Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Chung-Yi Li

  7. Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan

    Chung-Yi Li

  8. Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan

    Chung-Yi Li

  9. School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Edward Chia-Cheng Lai

  10. Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Kuan-Hung Liu

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  12. Kuan-Hung Liu
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Contributions

T.S.H. and K.H.L. conceptualized and designed the study. T.S.H., J.A.W., and Y.H.C. performed data curation. J.A.W. and K.H.L. provided supervision for data curation and the matching process. T.S.H. and J.A.W. conducted the main statistical analysis, assisted by K.H.L., J.A.W., and C.Y.L. who also advised on statistical aspects and interpretation of the data. T.S.H. wrote the original draft of the manuscript. W.R.L., P.W.C., E.C.C.L., J.M.S., M.C.W., and C.C.T. reviewed and edited the manuscript. All the authors participated in reviewing the manuscript and approved the final version to be published.

Corresponding author

Correspondence to Kuan-Hung Liu.

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This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of National Cheng Kung University Hospital (A-ER-110–327).

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All the authors declared no competing interests.

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Huang, TS., Wang, JA., Lin, WR. et al. The temporal association between percutaneous coronary intervention and intradialytic hypotension in hemodialysis patients. Ren Replace Ther 11, 17 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s41100-025-00611-0

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s41100-025-00611-0

Keywords

Renal Replacement Therapy

ISSN: 2059-1381

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