Perspective: peridialytic BP as a quality measure

Bottom line

• The measure asks one reading to do three jobs it cannot do: estimate volume status, predict cardiovascular outcome, and direct a session-level intervention. Several large dialysis organizations nonetheless use routine pre- and post-dialysis BP as a facility quality measure and as a prompt for more aggressive fluid management.
• It fails on prognostic validity. Once home and ambulatory BP were measured, neither pre-dialysis (P = 0.17) nor post-dialysis systolic BP (P = 0.997) predicted mortality ¹. At the facility level, having 20% more patients at a pre-dialysis systolic of 110–129 mmHg was associated with 13% higher mortality ².
• It fails on construct validity. Among fluid-overloaded patients, a low pre-dialysis systolic BP (below 110 mmHg) carried HR 1.52 for death ³. BP is not a volume measurement.
• The induced behavior has a known harm mechanism. Inside fixed chair time, the cheapest way to remove more fluid is a higher ultrafiltration rate, and rates above 13 mL/h/kg are associated with higher all-cause and cardiovascular mortality ^4,5.
• Keep the goal, change the instrument: a documented target-weight reassessment process (the one facility practice with a survival association, HR 0.78) ⁶, out-of-unit BP on file, and mandatory balancing measures with a lower bound.
• The most informative analysis costs nothing: overlay the IDH rate, ultrafiltration-rate distribution, saline rescue, and session shortening against the BP metric, by facility, since rollout.

1. The question

Several large dialysis organizations use routine pre- and post-dialysis blood pressure as a facility quality measure and as a prompt for more aggressive fluid management. This perspective evaluates that practice against the clinical evidence.

The position, stated plainly: the measure asks one reading to do three jobs it cannot do — estimate volume status, predict cardiovascular outcome, and direct a session-level intervention. The defensible version keeps the goal (volume control) and changes the metric, from a BP level to a reassessment process paired with hemodynamic guardrails.

What this perspective does not argue: it does not argue for permissive hypertension, therapeutic nihilism, or ignoring volume overload. Volume overload kills dialysis patients, BP lowering reduces cardiovascular events ⁷, and dry-weight probing works ⁸.

2. The clinical evidence the argument rests on

The case against the measure depends on measurement and prognostic evidence covered in detail elsewhere in this module (Which blood pressure matters). In brief:

• Out-of-unit BP predicts outcome. In the same patients, out-of-unit BP (home, ambulatory, or a standardized study-visit reading) relates to death and cardiovascular events, linearly in the CRIC analyses, while dialysis-unit systolic BP is null or U-shaped ^1,9,10.
• Peridialytic BP is imprecise. Pre-dialysis systolic BP overestimated ambulatory systolic BP with limits of agreement of +41.7 to −25.2 mmHg ¹¹, and detected ambulatory hypertension with 38.6% specificity ¹².
• It is poorly reproducible. Test–retest reliability runs home > ambulatory >> pre-dialysis > post-dialysis ¹³.
• The ultrafiltration rate is the main lever of intradialytic harm ^4,5,14.

None of this makes the in-center reading meaningless. Low in-center readings mark risk — facility-level pre-dialysis systolic BP of 110–129 mmHg ², a pre-dialysis systolic below 110 mmHg with fluid overload ³, and frequent intradialytic nadirs below 90 mmHg ¹⁵ all track with death. The accurate summary is that in-center BP is a poor target for chronic treatment and a real signal for the safety of the session.

3. Validity criteria

A quality measure has to clear four tests. Peridialytic BP fails or is untested on each:

4. Argument 1: the metric does not predict the outcome it proxies

A quality measure is a claim that moving the number moves the outcome. For peridialytic BP that claim has been tested head-to-head and failed. In 326 long-term hemodialysis patients with simultaneous home BP, 44-hour ambulatory BP, and two weeks of routine peridialytic readings, followed for a mean of 32 months (observational cohort) ¹:

Mortality was lowest at a home systolic of 120–130 and an ambulatory systolic of 110–120 mmHg, and out-of-unit BP was formally superior by likelihood ratio test ¹. The pattern replicates. Pre-dialysis systolic BP was the only metric not associated with cardiovascular events over 45.7 months in a Greek cohort ¹⁶, and in CRIC the dialysis-unit curve was U-shaped while the out-of-unit curve was linear for both death and cardiovascular events ^9,10.

5. Argument 2: the facility-level data point the other way

Robinson and colleagues analyzed 24,525 DOPPS patients with Cox models adjusted for patient and facility characteristics, specifically to reduce confounding by sick-patient physiology (observational) ²:

• Compared with a pre-dialysis systolic of 130–159 mmHg, mortality was 13% higher in facilities with 20% more patients at 110–129 mmHg, and 16% higher in facilities with 20% more patients at ≥160 mmHg.
• At the patient level, mortality was elevated at low (<130 mmHg), not high (≥180 mmHg), systolic BP.
• The authors’ explicit conclusion: their findings contrast with the KDOQI pre-dialysis target, and the facility range associated with the lowest risk was 130–159 mmHg — while acknowledging it may reflect unmeasured facility practices.

xychart-beta
    title "Facility pre-dialysis SBP mix and relative mortality (n=24,525)"
    x-axis "Facility pre-dialysis SBP band (mmHg)" ["110-129", "130-159", "160 or higher"]
    y-axis "Relative mortality vs 130-159 reference" 0.9 --> 1.25
    bar [1.13, 1.00, 1.16]

A metric that rewards facilities for shifting patients out of the 130–159 band and into 110–129 is, on the best available facility-level evidence, rewarding a 13% mortality excess. If the measure has no floor, that is the predicted failure mode, not a hypothetical one.

6. Argument 3: blood pressure is not a volume measurement

The metric’s implicit syllogism is high peridialytic BP → volume overload → remove more fluid. The MONDO analysis breaks the first arrow directly. Dekker and colleagues studied 8,883 hemodialysis patients with pre-dialysis multifrequency bioimpedance and one-year mortality follow-up (observational) ³:

• With fluid overload (+1.1 to +2.5 L), a pre-dialysis systolic BP <110 mmHg carried HR 1.52 (95% CI 1.06–2.17) for death. These patients need fluid removed; their BP says the opposite.
• With fluid depletion (below −1.1 L), a pre-dialysis systolic <140 mmHg was also associated with increased death: already over-ultrafiltrated, BP unremarkable.
• In normovolemia, low systolic BP (<110 mmHg) was associated with better survival (HR 0.46; 95% CI 0.23–0.91).

The authors’ conclusion is the sentence for the meeting: pre-dialysis systolic BP should be interpreted in the context of fluid status, not as an isolated marker ³.

flowchart TB
    subgraph FO["Fluid overload by bioimpedance, plus 1.1 to 2.5 L"]
        FO1["Pre-HD SBP under 110<br>HR 1.52 for death<br>NEEDS fluid off, BP says stop"]
        FO2["Pre-HD SBP high<br>Also increased risk<br>Metric and need agree"]
    end
    subgraph NV["Normovolemic"]
        NV1["Pre-HD SBP low<br>Associated with better survival<br>Metric would wrongly trigger action"]
        NV2["Pre-HD SBP high<br>Hypertension without overload<br>Needs drugs, not ultrafiltration"]
    end
    subgraph FD["Fluid depleted, under minus 1.1 L"]
        FD1["Pre-HD SBP under 140<br>Increased risk of death<br>Already over-ultrafiltrated"]
    end
    K["Pre-dialysis SBP alone<br>cannot identify who<br>needs more fluid removed"]
    FO1 --> K
    NV1 --> K
    NV2 --> K
    FD1 --> K
    style FO fill:#ffe0e0,stroke:#e03131,color:#000
    style NV fill:#d0ebff,stroke:#1971c2,color:#000
    style FD fill:#fff3bf,stroke:#f59f00,color:#000
    style FO1 fill:#ffa8a8,stroke:#c92a2a,color:#000
    style FO2 fill:#ffc9c9,stroke:#e03131,color:#000
    style NV1 fill:#b2f2bb,stroke:#2f9e44,color:#000
    style NV2 fill:#d0ebff,stroke:#1971c2,color:#000
    style FD1 fill:#ffa8a8,stroke:#c92a2a,color:#000
    style K fill:#ff6b6b,stroke:#c92a2a,color:#fff

Only one of the five cells is a case where metric and clinical need agree. In two the metric points the wrong way; in one it triggers ultrafiltration for a problem that requires antihypertensive drugs.

7. Argument 4: the induced behavior has a known harm mechanism

The metric does not remove fluid. Staff do, and the cheapest way to remove more fluid inside a fixed chair-time schedule is to raise the ultrafiltration rate — the variable most tightly linked to intradialytic harm. An ultrafiltration rate above 13 mL/h/kg is associated with higher all-cause and cardiovascular mortality ^4,5, and ultrafiltration volume with myocardial stunning ¹⁴.

flowchart TB
    M["Facility metric:<br>pre-HD SBP above threshold<br>or post-HD SBP above threshold"] --> T["Protocol response:<br>lower target weight,<br>take more fluid this session"]
    T --> U["Ultrafiltration rate rises<br>Session time unchanged"]
    U --> R["UF rate exceeds plasma refill"]
    R --> S1["Myocardial stunning<br>Regional wall motion abnormality"]
    R --> S2["Intradialytic hypotension<br>Nadir SBP under 90"]
    R --> S3["Gut, brain and kidney<br>hypoperfusion"]
    S1 --> H1["LV dysfunction, arrhythmia,<br>sudden cardiac death"]
    S2 --> H2["Access thrombosis,<br>session shortening,<br>saline rescue"]
    S3 --> H3["Mesenteric ischemia, dementia,<br>accelerated loss of<br>residual kidney function"]
    H2 --> F["Fluid given back<br>and target weight not reached"]
    F --> G["Higher starting weight and BP<br>at the next session"]
    G --> M
    style M fill:#fff3bf,stroke:#f59f00,color:#000
    style T fill:#ffe8cc,stroke:#e8590c,color:#000
    style U fill:#ffe8cc,stroke:#e8590c,color:#000
    style R fill:#ffc9c9,stroke:#e03131,color:#000
    style S1 fill:#ffa8a8,stroke:#c92a2a,color:#000
    style S2 fill:#ffa8a8,stroke:#c92a2a,color:#000
    style S3 fill:#ffa8a8,stroke:#c92a2a,color:#000
    style H1 fill:#ff6b6b,stroke:#c92a2a,color:#fff
    style H2 fill:#ff6b6b,stroke:#c92a2a,color:#fff
    style H3 fill:#ff6b6b,stroke:#c92a2a,color:#fff
    style F fill:#f8f9fa,stroke:#495057,color:#000
    style G fill:#f8f9fa,stroke:#495057,color:#000

7.1 The regulatory precedent

CMS moved toward an ultrafiltration rate measure for the ESRD Quality Incentive Program (QIP) — a metric with substantially better outcome evidence than peridialytic BP — and never scored it:

• The Kidney Care Quality Alliance measure (UFR ≥13 mL/kg/h in sessions under 240 minutes) was endorsed by the National Quality Forum in December 2015 ¹⁷. Flythe and colleagues modeled the two proposed specifications against a large dialysis organization’s 2012 database: facilities averaged 20.8–22.8% of patients above 13 mL/h/kg by the CMS monthly specification and 15.8% ± 8.2% by the KCQA annual specification, and larger facilities would need approximately 33 additional treatment hours per week to bring every patient under 13 with a 4-hour cap ¹⁸.
• CMS adopted UFR only as a reporting measure (data submission, not a performance threshold) beginning in Payment Year 2020, then removed it from the QIP beginning PY 2026 under the removal factor for measures that do not result in better or intended patient outcomes ¹⁹.
• The NKF-KDOQI Controversies Report judged adoption of a UFR threshold as a performance measure controversial and set out the research needed first ¹⁷.
• Flythe’s own summary: no published clinical trial has studied the impact of lowering ultrafiltration rates on clinical or patient-centered outcomes ²⁰.

If the program never scored a threshold for the variable with the strongest mechanistic and observational link to harm — and has now dropped even the reporting requirement — adopting one for a variable with a null prognostic association is difficult to justify.

8. The steelman: what genuinely supports the practice

State this first, in the room.

1. Volume overload is lethal and undertreated. Doing nothing is not neutral ^3,21.
2. Post-dialysis BP carries real volume information at the population level. In 531 patients assessed with multifrequency bioimpedance, a post-dialysis systolic rise of ≥10 mmHg tracked with extracellular overhydration and less weight removed ²², though another bioimpedance study found intradialytic hypertension equally common across volume states ²³.
3. BP responds to volume removal, making it a legitimate feedback signal ⁸.
4. BP lowering reduces hard outcomes in dialysis ⁷.
5. Systematic volume processes are associated with better survival. In DOPPS phase 4 (10,250 patients, 273 facilities), facilities with a protocol specifying how often dry weight is reassessed had lower all-cause (HR 0.78; 99% CI 0.64–0.94) and cardiovascular mortality (HR 0.72; 99% CI 0.55–0.95); routine orthostatic BP measurement was associated with lower all-cause hospitalization (HR 0.86) and fewer cardiovascular events (HR 0.85) ⁶.
6. The strict-volume-control school has a coherent case. Ok and colleagues argue that gradual, strict extracellular volume control normalizes BP without antihypertensive drugs, that high ultrafiltration rates rather than volume reduction itself drive the complications, and that transient intradialytic events on the way to euvolemia are outweighed by long-term cardiac benefit ²⁴. Note what this concedes: the tools are salt restriction and extra or longer sessions, not a faster pull inside fixed chair time.

And what does not exist: no randomized trial, and no observational study, has tested whether a peridialytic-BP-triggered ultrafiltration protocol improves any patient outcome.

9. A defensible measure set

9.1 Primary measures (process-based)

9.2 Balancing measures (mandatory, reported alongside)

10. Anticipated rebuttals

“We are following KDOQI: pre-dialysis BP <140/90.” That recommendation was graded C — opinion-based, extrapolated from the general population with no trial-level evidence in dialysis ²⁶ — and the 2015 KDOQI update set no BP target at all ²⁷. The most recent comprehensive guideline, UKKA 2025, suggests a pre-dialysis systolic range of 140–165 mmHg (grade 2B) for units using in-centre readings, and sets no home-BP target ²⁸; KDIGO 2020 emphasizes avoiding overly low BP ²⁵. Citing a 2005 opinion-based target as the basis for a current metric is the weakest ground in the discussion.

“Volume overload kills our patients. We have to act.” Agreed, and the steelman concedes it. The disagreement is that pre-dialysis BP is a poor detector of volume overload ³ and post-dialysis BP is the least reproducible metric available ^13,29. Act on volume with volume measurements; act on blood pressure with blood pressure measurements that predict outcome.

“Home BP and ABPM are not feasible for in-center patients.” HDPAL managed 200 in-center patients on monthly home BP over years ³⁰; a pilot randomized trial specifically tested the strategy and found 97% adherence ³¹. The barrier is workflow and cost, not feasibility — a solvable problem, not a reason to substitute an invalid metric.

“The metric only flags patients. It does not force ultrafiltration.” Then the operational definitions should be harmless to publish. Ask for the exact numerator and denominator; whether facility performance is ranked, reported upward, or tied to any incentive; what specifically is expected at the chair when a patient is flagged; and whether any balancing measure is reported alongside it. A flag with no paired denominator is a one-directional pressure.

“Lower blood pressure is better in every other population.” True for blood pressure. The quantity in this metric is a single seated reading at the peak or trough of a volume cycle, in a patient often anxious and frequently off their morning dose. Measured properly in the same population, the relationship straightens out, with a mortality nadir around a home systolic of 120–130 mmHg ¹ and linear out-of-unit associations in CRIC ^9,10.

“Our UFR cap of 13 mL/h/kg protects patients.” 13 mL/h/kg is where excess mortality was demonstrated relative to ≤10, not a safe operating point ⁴. In 118,394 patients, a UFR above 10 was also associated with greater mortality (adjusted HR 1.22) across subgroups ⁵, and KDIGO notes associations as low as 6 mL/h/kg ²⁵. A cap set at the demonstrated harm threshold, combined with a metric pushing toward it, concentrates the population just under the line.

“We already monitor intradialytic hypotension separately.” Then show the two datasets together, by facility, over the period the BP metric has been in place. If it is working benignly, pre-dialysis systolic BP should have fallen without a rise in nadir-below-90 rates, saline rescue, or shortened sessions. This requires no new data collection and is the single most informative analysis available internally.

“You are advocating permissive hypertension.” No. The recommendation targets home BP <135/85 or ambulatory BP <130/80 mmHg — tighter than the UKKA pre-dialysis envelope — reached primarily through sodium restriction, target-weight probing, treatment time, and appropriately timed antihypertensives ^28,32.

“Post-dialysis BP correlates with overhydration — there is published evidence.” There is, and the steelman concedes it ²². But a population-level association is not an individual-level decision rule. The same literature shows post-dialysis BP is the least reproducible metric in the set ¹³, and it did not predict mortality at all in head-to-head comparison ¹.

“Is it fair to tell staff there is no evidence that pre- or post-dialysis BP affects mortality?” Half fair. Pre- and post-dialysis readings did not predict mortality once home and ambulatory BP were measured ¹, and no trial shows that lowering them helps ³³. But low in-center readings are not prognostically silent ^2,3,15. “The other 44 hours” is shorthand: the long interdialytic interval is approximately 68 hours, and the out-of-unit association is prognostic, not proof of cause ^1,9,34.

“What is your evidence that a different metric would do better?” In DOPPS, a protocol specifying reassessment frequency was associated with 22% lower all-cause and 28% lower cardiovascular mortality — the largest facility-level effect in the study, and larger than anything attributable to a BP threshold ⁶.

“What would change your mind?” A cluster-randomized trial of facilities assigned to a peridialytic-BP-triggered volume protocol versus usual care, with mortality or cardiovascular hospitalization as the primary endpoint and IDH, ultrafiltration rate, and residual kidney function prespecified as balancing outcomes. That design is achievable within a large dialysis organization: RESOLVE uses exactly this unit-level cluster randomization for dialysate sodium, targeting more than 300 clusters, and has not yet reported ³⁵. Internally, an interrupted time series before and after metric rollout, with IDH and ultrafiltration rate as co-primary outcomes, would be highly informative.

11. Governance pathway

Proposed motion language for a facility governing body:

That the governing body request from the organization (a) the published operational definition of the peridialytic blood pressure quality measure, including numerator, denominator, thresholds, and the expected clinical action when a patient is flagged; (b) a facility-level analysis overlaying intradialytic hypotension rate, ultrafiltration rate distribution, saline rescue rate, and session-shortening rate against the blood pressure measure for the period since implementation; and (c) referral of the measure specification to the Chief Medical Officer for organization-wide review with facility medical director representation, with a view to adopting balancing measures and a lower bound enterprise-wide.

Concessions to make out loud, first:

• Volume overload is a genuine, undertreated, lethal quality problem. The initiative’s intent is correct.
• BP lowering does reduce cardiovascular events in dialysis ⁷. This is not an argument for nihilism.
• Peridialytic BP is free, universally collected, and available in real time. No alternative matches that operationally.
• Low in-center readings do carry prognostic information ^2,3,15. The argument is that the metric has no validity as a treatment target, not that the readings are meaningless.
• The evidence against the metric is observational. No randomized trial shows that a peridialytic-BP-driven protocol causes harm — only that the metric lacks prognostic validity, that facility-level low BP tracks with excess mortality, and that the induced behavior has a well-characterized harm mechanism.
• Structured, protocolized volume management is associated with better survival ⁶. A process is needed. The disagreement is about what it keys on.

Evidence gaps

• No trial of any BP-based quality measure in dialysis has been conducted, in either direction; the one volume-related QIP measure (UFR reporting) was removed for failing to improve outcomes ¹⁹.
• No adequately powered trial of a BP target exists in hemodialysis. BID was a 126-patient pilot with a safety signal and no definitive answer ³³; KDIGO 2020 and UKKA 2025 both list target trials as the top research need ^25,28.
• No randomized trial has tested a home-BP-guided versus pre-dialysis-BP-guided strategy for hard outcomes; only a 50-patient, 4-month feasibility pilot exists ³¹.
• No published trial has studied lowering ultrafiltration rates for clinical or patient-centered outcomes ²⁰.
• The facility-level evidence is observational and may reflect unmeasured facility practices, as its authors acknowledge ².

References

Adapted from the author’s canonical review Blood Pressure in the Dialysis Patient (reference-checked 2026-09-26; every journal reference matched to its PubMed record). Numbering is local to this page.

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19. Centers for Medicare & Medicaid Services. ESRD Quality Incentive Program Payment Year 2026 fact sheet (CY 2024 ESRD PPS final rule): Ultrafiltration Rate reporting measure removed from the ESRD QIP measure set beginning PY 2026 under measure removal factor 2. The UFR reporting measure was originally adopted for PY 2020 (CY 2017 ESRD PPS final rule). Regulatory document; no PubMed record.
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26. K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis. 2005;45(4 Suppl 3):S1–S153. PMID: 15806502
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28. Doulton T, Adam M, Durman K, et al. Management of blood pressure in adults, children and young people on dialysis: UK Kidney Association clinical practice guideline. BMC Nephrol. 2025;26(1):532. PMID: 41013409
29. Iatridi F, Theodorakopoulou MP, Sarafidis P. Post-dialytic blood pressure in hemodialysis patients: still an inaccurate metric. Hypertens Res. 2025;48(6):2012–2013. PMID: 40175675
30. Agarwal R, Sinha AD, Pappas MK, Abraham TN, Tegegne GG. Hypertension in hemodialysis patients treated with atenolol or lisinopril: a randomized controlled trial. Nephrol Dial Transplant. 2014;29(3):672–681. PMID: 24398888
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32. Sarafidis PA, Persu A, Agarwal R, et al. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the ERA-EDTA and the Hypertension and the Kidney working group of the ESH. Nephrol Dial Transplant. 2017;32(4):620–640. PMID: 28340239
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Also in this module

Blood pressure, volume, and the dialysis prescription, one question per page.

• Which blood pressure matters: measurement and prognosis
• Treating hypertension on dialysis: targets, trials, agents, dose timing
• Intradialytic hypertension and the stability trade-off
• Estimating dry weight: assessment, tools, probing
• Ultrafiltration rate and treatment time
• Intradialytic hypotension and dialysate cooling
• Dialysate sodium: BP, thirst, IDH, and the RESOLVE question
• Maintenance Hemodialysis — module index
• Hypertension — advanced module