1. CHAPTER 8: Blood Pressure Control and Dyslipidaemia in Patients on Dialysis S. Prasad Menon Hooi Lai Seong Lee Wan Tin Sunita Bavanandan Source: 21 st MDTR Report 2013, NRR

2. Table 8.1.1: Distribution of pre dialysis systolic blood pressure, HD patients 2004-2013 Year Number of patients MeanSDMedianLQUQ % Patients <120 mmHg % Patients 120-<140 mmHg % Patients 140-<160 mmHg % Patients 160-<180 mmHg % Patients ≥180 mmHg 2004 7936149.720150136.6163.172339256 2005 9220149.919.4149.6137162.862440246 2006 11525151.419.3151.1138.816452241257 2007 12830152.119.1151.9139.3164.752140277 2008 15318152.119152139.4164.642140277 2009 1787815119150.6138.2163.552341256 2010 19432150.818.9150.4138.3163.352341256 2011 22215151.618.9151.513916442241266 2012 25596151.519151.313916452241267 2013 28818151.918.7151.9139.716442142267

3. Source: 21 st MDTR Report 2013, NRR Figure 8.1.1: Cumulative distribution of pre dialysis systolic blood pressure, HD patients 2004-2013

4. Source: 21 st MDTR Report 2013, NRR Table 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 2004-2013 Year Number of patients MeanSDMedianLQUQ % Patients <120 mmHg % Patients 120-<140 mmHg % Patients 140-<160 mmHg % Patients 160-<180 mmHg % Patients ≥180 mmHg 2004 125914119.8140.9127.4154.5133436143 2005 1351140.420.2139.3127.3153.2133832143 2006 1523139.319.3138.4126.7151.6144032112 2007 1753139.919.2139.4127152.8153733132 2008 2049139.418.7139.5126.7151.4153635122 2009 2177140.718.7140.5128.1153.41335 142 2010 232714017.8140128.3151.4123738112 2011 251714018140.2128.2151.8133638112 2012 2734141.118.3141.3128.7153.1123438142 2013 294014218.3141.8130.1154.4113439142

5. Source: 21 st MDTR Report 2013, NRR Figure 8.1.2: Distribution of pre dialysis systolic blood pressure, PD patients 2004-2013

6. Source: 21 st MDTR Report 2013, NRR Table 8.1.3: Distribution of pre dialysis diastolic blood pressure, HD patients 2004-2013 Year Number of patients MeanSDMedianLQUQ % Patients <70 mmHg % Patients 70-<80 mmHg % Patients 80-<90 mmHg % Patients 90-<100 mmHg % Patients ≥100 mmHg 2004 793480.310.280.373.686.9153336143 2005 922080.310.680.473.587153236143 2006 1152480.411.180.473.387.1163235143 2007 1283080.411.180.273.187163234144 2008 1531679.811.179.672.486.71833 133 2009 1787779.71279.27286.4193331124 2010 1943079.411.87971.886.2203431124 2011 2221479.211.978.871.686.1203430124 2012 2559378.811.878.47185.8223430114 2013 2881678.81278.370.985.8223329114

7. Source: 21 st MDTR Report 2013, NRR Figure 8.1.3: Cumulative distribution of pre dialysis diastolic blood pressure, HD patients 2004-2013

8. Source: 21 st MDTR Report 2013, NRR Table 8.1.4: Distribution of pre dialysis diastolic blood pressure, PD patients 2004-2013 Year Number of patients MeanSDMedianLQUQ % Patients <70 mmHg % Patients 70-<80 mmHg % Patients 80-<90 mmHg % Patients 90-<100 mmHg % Patients ≥100 mmHg 2004 125882.210.58375.489.2112838184 2005 135181.610.982.27588.3122940155 2006 152281.310.681.574.888132840153 2007 175280.610.780.77486.9143238123 2008 204979.710.1807386.3163236132 2009 217780.210.380.273.586.9153335143 2010 232779.910.48072.986.8173334133 2011 251779.910.38073.386.7163336132 2012 273781.212.180.873.887.8153135154 2013 293380.610.980.773.687.5153235154

9. Source: 21 st MDTR Report 2013, NRR Figure 8.1.4: Cumulative Distribution of pre dialysis diastolic blood pressure, PD patients 2004-2013

10. Source: 21 st MDTR Report 2013, NRR Table 8.1.5(a): Median systolic blood pressure among HD patients, HD centres Year Number of centres Min 5 th Centile LQ Media n UQ 95 th Centile Max 2004 217122.1137.5145.8150155.4162.8169.8 2005 239121.7137144.3150.7154.9162.2171.8 2006 286130.8138.8146.4151.5156.5162.9180.1 2007 319131.7140.5147.4152.3157164.9174.1 2008 376133.5141.2147.5152.5157164.3174.3 2009 426133.2139.8146.8151.2155.7162.6173.2 2010 460130.1140.2146.3150.1155.7163.2175 2011 513125.5139.7147.5151.6156.6163.8175.3 2012 566128.8140.8147.6151.8156.2163.2170.7 2013 610124.4141148.4152.5157165.3174.8

11. Source: 21 st MDTR Report 2013, NRR Figure 8.1.5(a): Variation in median systolic blood pressure among HD patients, HD centres 2013

12. Source: 21 st MDTR Report 2013, NRR Table 8.1.5(b): Median diastolic blood pressure among HD patients, HD centres Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 21770.27478.380.782.586.888.4 2005 2396973.178.180.882.786.390.1 2006 2866874.477.880.383.286.7101 2007 31970.173.377.880.182.987.3124.6 2008 37666.873.477.279.582.586.892.3 2009 42668.572.876.779.48286.1133.8 2010 46068.672.576.679.382.186142.2 2011 51367.872.876.378.681.586.2143 2012 56666.371.375.978.581.386.3122.8 2013 61061.870.875.578.381.886129.8

13. Source: 21 st MDTR Report 2013, NRR Figure 8.1.5(b): Variation in median diastolic blood pressure among HD patients, HD centres 2013

14. Source: 21 st MDTR Report 2013, NRR Table 8.1.5(c): Proportion of HD patients with pre dialysis blood pressure <140/90 mmHg, HD centres Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 217082029385782 2005 2395112028385695 2006 286091724345276 2007 319071726334875 2008 376071724.532.54669 2009 4260101826.5345080 2010 460081826365087 2011 513071724335094 2012 566081825334680 2013 610071623314693

15. Source: 21 st MDTR Report 2013, NRR Figure 8.1.5(c): Variation in proportion of HD patients with pre dialysis blood pressure <140/90 mmHg, HD centers 2013

16. Source: 21 st MDTR Report 2013, NRR Table 8.1.6(a): Median systolic blood pressure among PD patients, PD centres 2004-2013 Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 18122.9 134.5139.8143.3149.7 2005 19122.6 133.3136.6142158 2006 22112.7118.3130.2136.3140.4146154.9 2007 22115.9116.3135.2138.2142.5148153.5 2008 23115.6118.1136138.9142.1147.7147.8 2009 24113.5116.3135.3138.3144.3149.9161.5 2010 26114.3115.6133.3138.6143.3146.3147.9 2011 27112.5114.2132.2140.3142.3146.5147.8 2012 28114114.3132.4140.9143.5149.8156.7 2013 27112115.5135142145.4158.7161.5

17. Source: 21 st MDTR Report 2013, NRR Figure 8.1.6(a): Variation in median systolic blood pressure among PD patients, PD centres 2013

18. Source: 21 st MDTR Report 2013, NRR Table 8.1.6(b): Median diastolic blood pressure among PD patients, PD centres 2004-2013 Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 1877.5 80.883.484.387 2005 1974.4 80.382.984.286 2006 2271.67478.981.582.486.388.4 2007 2268.877.378.980.482.183.286.9 2008 2373.47677.98082.185.586.6 2009 2472.973.378.579.282.384.487.8 2010 2672.875.777.379.581.786.387.4 2011 277274.178.379.881.985.186.9 2012 2872.17378.680.183.486.691 2013 2770.475.577.681.482.886.890.4

19. Source: 21 st MDTR Report 2013, NRR Figure 8.1.6(b): Variation in median diastolic blood pressure among PD patients, PD centres 2013

20. Source: 21 st MDTR Report 2013, NRR Table 8.1.6(c): Proportion of PD patients with pre dialysis blood pressure <140/90 mmHg, PD centres 2004-2013 Year Number of centre Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 1830 38475673 2005 1923 43556292 2006 221836435967100 2007 2227 4454.56791 2008 23282943535885100 2009 2410294052579296 2010 2630343850.56388100 2011 27293141457197100 2012 285264044.563.590100 2013 27172236416893100

21. Source: 21 st MDTR Report 2013, NRR Figure 8.1.6(c): Variation in proportion of PD patients with pre dialysis blood pressure < 140/90 mmHg, PD centres 2013

22. Source: 21 st MDTR Report 2013, NRR Table 8.1.7(a): Correlation of blood pressure profile and death, cardiovascular death and ischaemic heart disease, dialysis patients 2004-2013 SBP<120 and DBP<70 (I) SBP 120-140 and DBP 70-80 (II) SBP 140-160 and DBP 80-90 (III) SBP 160-180 and DBP 90-100 (IV) SBP>=180 and DBP>=100 (V) n%n%n%n%n% Men n 601100226910040881001105100186100 Death 2995082636115628326307138 CVD/IHD 991622310208542495 Women n 60810017811002460100531100111100 Death 254425092963726162314641 CVD/IHD 508112698417355

23. Source: 21 st MDTR Report 2013, NRR Figure 8.1.7(a): Relationship between blood pressure and death in dialysis patients 2004-2013

24. Source: 21 st MDTR Report 2013, NRR Table 8.1.7(b): Hazard ratio for death in each of the blood pressure categories, 2004-2013 SBP<120 and DBP<70 * Ref. SBP 120-140 and DBP 70-80 SBP 140-160 and DBP 80-90 SBP 160-180 and DBP 90-100 SBP>=180 and DBP>=100 Men n 601226940881105186 Hazard ratio 1.00 0.5090.3080.3450.745 95% CI (0.445 ; 0.581)(0.271 ; 0.35)(0.295 ; 0.404)(0.575 ; 0.965) p-value <0.001 0.026 Women n 60817812460531111 Hazard ratio 1.000.5260.4070.5511.76 95% CI (0.452 ; 0.611)(0.352 ; 0.471)(0.452 ; 0.671)(1.285 ; 2.411) p-value <0.001

25. Source: 21 st MDTR Report 2013, NRR Table 8.2.1: Distribution of serum cholesterol, HD patients 2004-2013 Year Number of patients MeanSDMedianLQUQ % patients <3.5 mmol/L % patients 3.5-<5.3 mmol/L % patients 5.3-<6.2 mmol/L % patients ≥6.2 Mmol/L 2004 67094.71.14.745.41159228 2005 79054.71.14.645.31260208 2006 101384.61.14.63.95.31461187 2007 113474.61.14.53.85.21462186 2008 138214.51.14.43.85.21562176 2009 159114.61.14.53.85.21462176 2010 176534.61.14.53.85.21462187 2011 203864.51.14.43.85.11663156 2012 233484.51.14.43.85.11663155 2013 263504.51.14.43.85.11663155

26. Source: 21 st MDTR Report 2013, NRR Figure 8.2.1: Cumulative distribution of cholesterol, HD patients 2004-2013

27. Source: 21 st MDTR Report 2013, NRR Table 8.2.2: Distribution of serum cholesterol, PD patients 2004-2013 Year Number of patients MeanSDMedianLQUQ % patients <3.5 mmol/L % patients 3.5-<5.3 mmol/L % patients 5.3-<6.2 mmol/L % patients ≥6.2 mmol/L 2004 12305.31.45.24.46.15472721 2005 12425.21.354.35.95532418 2006 13955.21.45.14.35.96502618 2007 16295.11.35.14.25.98482618 2008 19025.21.454.35.97502418 2009 20165.31.55.14.366482620 2010 21865.21.45.14.367482520 2011 22915.11.354.25.88502517 2012 26285.11.44.94.35.87522417 2013 294451.44.84.15.79552215

28. Source: 21 st MDTR Report 2013, NRR Figure 8.2.2: Cumulative distribution of cholesterol (mmol/L), PD patients 2004-2013

29. Source: 21 st MDTR Report 2013, NRR Table 8.2.3: Distribution of serum triglyceride, HD patients 2004-2013 Year Number of patients MeanSDMedianLQUQ % patients <1.7 mmol/L % patients 1.7-<2.3 mmol/L % patients 2.3-<3.5 mmol/L % patients ≥3.5 mmol/L 2004 560721.21.71.22.451231710 2005 695021.31.71.22.450221810 2006 952221.31.61.22.35421169 2007 108821.91.21.61.12.35521168 2008 129281.91.21.61.12.35620158 2009 151901.91.31.61.12.35421169 2010 169701.91.31.61.12.35421169 2011 195641.91.21.61.12.35521168 2012 228121.91.21.61.12.35421169 2013 257411.91.21.61.12.35520168

30. Source: 21 st MDTR Report 2013, NRR Figure 8.2.3: Cumulative distribution of serum triglyceride, HD patients 2004-2013

31. Source: 21 st MDTR Report 2013, NRR Table 8.2.4: Distribution of serum triglyceride, PD patients 2004-2013 Year Number of patients MeanSDMedianLQUQ % patients <1.7 mmol/L % patients 1.7-<2.3 mmol/L % patients 2.3-<3.5 mmol/L % patients ≥3.5 mmol/L 2004 12232.21.61.81.32.647231713 2005 12412.21.51.81.32.743241814 2006 13912.21.61.71.22.647211813 2007 16252.11.41.81.32.645241912 2008 19072.21.51.81.32.745212014 2009 20172.21.61.81.32.746212014 2010 21772.11.41.81.32.547231811 2011 230921.31.71.22.35123179 2012 262421.31.71.22.548231910 2013 296221.31.61.22.35223179

32. Source: 21 st MDTR Report 2013, NRR Figure 8.2.4: Cumulative distribution of serum triglyceride, PD patients 2004-2013

33. Source: 21 st MDTR Report 2013, NRR Table 8.2.5(a): Median serum cholesterol level among HD patients, HD centres 2004-2013 Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 1863.94.24.54.74.95.46.1 2005 2123.84.14.44.64.85.35.6 2006 2693.33.94.34.64.85.25.9 2007 2923.644.34.54.85.15.4 2008 3463.23.84.24.54.75.16.3 2009 3833.53.94.34.54.85.25.6 2010 4233.544.34.54.85.15.6 2011 4873.73.94.24.44.64.95.7 2012 5493.544.24.44.64.95.8 2013 5843.43.94.24.44.64.95.5

34. Source: 21 st MDTR Report 2013, NRR Figure 8.2.5(a): Variation in median serum cholesterol level among HD patients, HD centres 2013

35. Source: 21 st MDTR Report 2013, NRR Table 8.2.5(b): Proportion of HD patients with serum cholesterol <5.3mmol/L, HD centres 2004-2013 Year Number of centre Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 18625446069768997 2005 2123448657380.591100 2006 269295267758392100 2007 292365769758493100 2008 346295669778592100 2009 383335068768493100 2010 423275568768492100 2011 487275871798694100 2012 549336373798693100 2013 584426273808694100

36. Source: 21 st MDTR Report 2013, NRR Figure 8.2.5(b): Variation in proportion of patients with serum cholesterol <5.3 mmol/L, HD centres 2013

37. Source: 21 st MDTR Report 2013, NRR Table 8.2.5(c): Median serum triglyceride level among HD patients, HD centres 2004-2013 Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 1601.11.31.51.61.82.23 2005 1940.91.31.51.61.82.22.6 2006 25611.31.51.61.82.34 2007 2780.81.21.41.61.82.12.9 2008 31911.21.41.61.722.5 2009 36411.21.41.61.82.12.6 2010 4050.91.21.51.61.82.22.9 2011 46811.21.41.61.826.5 2012 5340.81.21.41.61.82.13 2013 5720.91.21.41.61.82.12.5

38. Source: 21 st MDTR Report 2013, NRR Figure 8.2.5(c): Variation in median serum triglyceride level among HD patients, HD centers 2013

39. Source: 21 st MDTR Report 2013, NRR Table 8.2.5(d): Proportion of HD patients with serum triglyceride <2.1 mmol/L, HD centres Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 160195059707986.597 2005 19426476067748593 2006 256144764707788100 2007 278365263707989100 2008 319335464728088100 2009 364365062.5717890100 2010 40527506370788894 2011 46805364717888100 2012 534235063707888100 2013 572405064717988100

40. Source: 21 st MDTR Report 2013, NRR Figure 8.2.5(d): Variation in proportion of patients with serum triglyceride <2.1mmol/L, HD centers 2013

41. Source: 21 st MDTR Report 2013, NRR Table 8.2.6(a): Median serum cholesterol level among PD patients, PD centres 2004-2013 Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 184.6 4.95.35.46.1 2005 194.4 4.755.45.9 2006 214.44.64.855.36.16.2 2007 214.5 4.85.25.45.56.1 2008 224.34.54.85.15.45.65.8 2009 234.7 4.85.15.45.96.7 2010 254.6 4.95.15.467.3 2011 264.34.44.95.15.45.97.2 2012 274.4 4.855.367.8 2013 274.4 4.74.95.25.77.3

42. Source: 21 st MDTR Report 2013, NRR Figure 8.2.6(a): Variation in median serum cholesterol level among PD patients, PD centres 2013

43. Source: 21 st MDTR Report 2013, NRR Table 8.2.6(b): Proportion of PD patients with serum cholesterol <5.3 mmol/L, PD centres 2004-2013 Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 1829 4249.56069 2005 1927 45576974 2006 2120254757647179 2007 2129404553657486 2008 22304046556873 2009 239334552667276 2010 259274351607172 2011 260234553.5647388 2012 2711204860677781 2013 2712375262697879

44. Source: 21 st MDTR Report 2013, NRR Figure 8.2.6(b): Variation in proportion of patients with serum cholesterol <5.3 mmol/L, PD centres 2013

45. Source: 21 st MDTR Report 2013, NRR Table 8.2.6(c): Median serum triglyceride level among PD patients, PD centres 2004-2013 Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 181.3 1.71.8 2.2 2005 191.4 1.61.922.2 2006 211.11.41.61.81.922.6 2007 211.21.51.71.81.92.12.7 2008 221.31.51.71.822.22.3 2009 231.41.51.71.81.92.22.5 2010 241.41.51.61.71.92.1 2011 261.21.41.6 1.82.12.2 2012 271.4 1.51.71.92.52.7 2013 271.31.41.6 1.82.12.6

46. Source: 21 st MDTR Report 2013, NRR Figure 8.2.6(c): Variation in median serum triglyceride level among PD patients, PD centres 2013

47. Source: 21 st MDTR Report 2013, NRR Table 8.2.6(d): Proportion of PD patients with serum triglyceride < 2.1 mmol/L, PD centres 2004-2013 Year Number of centres Min 5 th Centile LQMedianUQ 95 th Centile Max 2004 1847 60626888 2005 1940 54606891 2006 2133525561637782 2007 2140525865678081 2008 2248 5861.5658385 2009 2327485460677071 2010 24495059.56268.57479 2011 2641536569.5738193 2012 2729446064718086 2013 2738506369738591

48. Source: 21 st MDTR Report 2013, NRR Figure 8.2.6(d): Variation in proportion of patients with serum triglyceride <2.1 mmol/L, PD centres 2013

49. Source: 21 st MDTR Report 2013, NRR Table 8.2.7(a): Relationship of different categories of cholesterol levels with death, dialysis patients 2004 -2013 <3.5 mmol/L 3.5-<5.3 mmol/L 5.3-<6.2 mmol/L >=6.2 mmol/L n%n%n%n% Men n 3767100154041003188100960100 Death 14743949103210093234836 CVD/IHD 3299103071926596 Women n 13841001120510044121001909100 Death 6194534293113213063633 CVD/IHD 1249611520651166

50. Source: 21 st MDTR Report 2013, NRR Figure 8.2.7(a): Relationship between serum cholesterol categories and death, dialysis patients 2004-2013

51. Source: 21 st MDTR Report 2013, NRR Table 8.2.7(b): Hazard ratio for death in each of the total cholesterol categories, dialysis patient 2004-2013 <3.5 mmol/L Ref. 3.5-<5.3 mmol/L 5.3-<6.2 mmol/L >=6.2 mmol/L Men n 3767154043188960 Hazard ratio1.00 0.6750.7671.227 95% CI (0.601 ; 0.675)(0.654 ; 0.767)(0.971 ; 1.227) p-value <0.001 0.143 Women n 13841120544121909 Hazard ratio 1.000.5230.5430.81 95% CI (0.44 ; 0.523)(0.448 ; 0.543)(0.649 ; 0.81) p-value <0.001