－ Higher SBP visit-to-visit variability (SBV) has been associated ■ Background － Higher SBP visit-to-visit variability (SBV) has been associated 　　　with increased risk of mortality. － Little is known about the association of pre-end-stage renal disease (ESRD) SBV with outcomes after dialysis initiation. ■ Aim － Investigate the association of pre-ESRD SBV with post-ESRD all-cause, cardiovascular, and infection-related mortality.

Materials and Methods ■ Study design 　 － Retrospective cohort study from TC-CKD cohort (n = 52,172) ■ Analytic sample 　 － 17,729 US veterans who transitioned to dialysis from October 2007 through September 2011 ■ Inclusion criteria 　 － with at least 3 outpatient BP measurements during one year prior to dialysis initiation (i.e., one-year “prelude period”) ■ Exposure variable 　 － SBV defined as the SD of the intra-individual outpatient SBP values in each patient measured during the one-year prelude period, and categorized into quartiles (<11.6, 11.6-<15.7, 15.7-<20.4, ≥20.4 mmHg)

Materials and Methods (cont.) ■ Outcomes － Factors associated with higher prelude SBV － All-cause, cardiovascular, and infection-related mortality after dialysis initiation ■ Statistical Analysis 　 － Multivariable linear regression 　 － Cox models (for all-cause) and competing risk regressions (for cause-specific mortality) with adjustment for potential confounders; Model 1: crude Model 2: demographics Model 3: model 2 + comorbidities, SBP, BMI, eGFR Model 4: model 3 + medications, CV drug adherence, access type

Factors associated with prelude SBV Characteristics Coefficient* 95% CI Age (per 1 year) -0.03 -0.04 to -0.02 Marital status (married vs. non-married) -0.44 -0.64 to -0.25 Systolic BP (per 1 mmHg) 0.15 0.14 to 0.16 Body mass index (per 1 kg/m2) -0.10 -0.11 to -0.08 Comorbidities (yes vs. no)   Diabetes mellitus 0.64 0.38 to 0.90 Cardiovascular disease 0.44 0.23 to 0.66 Peripheral vascular disease 0.39 0.18 to 0.60 Medications (yes vs. no) ACEIs/ARBs 0.65 0.44 to 0.85 β-blockers 0.88 0.64 to 1.13 Vasodilators 0.96 0.56 to 1.36 Erythropoiesis-stimulating agents 0.74 0.53 to 0.95 CV medication adherence (>80% vs. ≤80%) -0.80 -1.02 to -0.57 Vascular access type (catheter vs. others) 0.34 0.13 to 0.56 Laboratory parameters Serum albumin (per 1 g/dL) -0.82 -1.00 to -0.65 Variables in red indicate modifiable factors. *Coefficient for multivariable linear regression models.

infection-related death risk, associated with high pre-ESRD SBV. ■　Clinical implications 　－ Physicians need to be aware of the post-ESRD death risk, particularly infection-related death risk, associated with high pre-ESRD SBV. 　－ SBV could become a treatment target through interventions aimed at modifiable clinical factors. ■　Conclusions 　－ Greater pre-ESRD SBV, a potentially modifiable risk factor, was independently associated with higher all-cause and infection-related mortality after dialysis initiation. 　－ Further studies are needed to test whether modification of pre-ESRD SBV can improve clinical outcomes among incident ESRD patients.