JAN

JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

The effectiveness of intensive nursing care on seasonal variation of

blood pressure in patients on peritoneal dialysis
Lei Quan, Jie Dong, Yanjun Li & Li Zuo
Accepted for publication 13 August 2011

Correspondence to L. Zuo:
e-mail: [email protected]
Lei Quan RN
Nurse
Renal Division, Department of Medicine,
Peking University First Hospital,
Institute of Nephrology, Peking University,
and,
Key Laboratory of Renal Disease, Ministry of
Health of China, Beijing, China
Jie Dong MD PhD
Doctor
Renal Division, Department of Medicine,
Peking University First Hospital,
Institute of Nephrology, Peking University,
and,
Key Laboratory of Renal Disease, Ministry of
Health of China, Beijing, China
Yanjun Li MD
Dietitian
Renal Division, Department of Medicine,
Peking University First Hospital,
Institute of Nephrology, Peking University,
and,
Key Laboratory of Renal Disease, Ministry of
Health of China, Beijing, China
Li Zuo MD
Doctor
Renal Division, Department of Medicine,
Peking University First Hospital,
Institute of Nephrology, Peking University,
and,
Key Laboratory of Renal Disease, Ministry of
Health of China, Beijing, China

 2011 Blackwell Publishing Ltd

Q U A N L . , D O N G J . , L I Y . & Z U O L . ( 2 0 1 2 ) The effectiveness of intensive nursing

care on seasonal variation of blood pressure in patients on peritoneal dialysis.
Journal of Advanced Nursing 68(6), 12671275. doi: 10.1111/j.1365-2648.2011.
05833.x

Abstract
Aim. This article is a report of a study to reduce the seasonal variation of blood
pressure in patients on peritoneal dialysis through an intensive programme of
nursing care.
Background. The seasonal variation of blood pressure is a common phenomenon in
patients on maintenance dialysis. Whether or not this variation can be reduced
through a given intervention is unknown.
Methods. The programme of intensive nursing care including education on volume
control, home blood pressure monitoring and intensified antihypertensive treatment,
was implemented from December 2006. The blood pressure, fluid and sodium removal and defined daily doses of antihypertensive agents were measured at 1monthly intervals and averagely quarterly for seasonal values for spring, summer,
autumn and winter, respectively, before (December 2005November 2006) and
after intervention (December 2006November 2007).
Findings. A total of 76 clinically stable patients on peritoneal dialysis were enrolled
and finally analysed. The mean age was 606 years, and dialysis duration was
232 months. Before intervention, there were important seasonal variations in systolic and diastolic blood pressure. After intensive nursing care was implemented, the
seasonal variation of systolic blood pressure disappeared. The diastolic blood
pressure still represented a season pattern, but the discrepancy between winter and
summer decreased. There were no seasonal patterns of total fluid and sodium
removal before and after intervention.
Conclusions. Intensive nursing care reduced the seasonal variation of blood pressure in patients on peritoneal dialysis. These data provided an evidence for implementing nurse-centred interventions in this population.
Keywords: blood pressure, nurse, seasonal variation

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L. Quan et al.

Introduction
Hypertension is a major risk factor for cardiovascular events in
the general population and patients with end stage renal disease.
Seasonal variation of blood pressure, with higher values in the
winter and lower values in the summer, was reported to be a
common phenomenon in haemodialysis patients more than
10 years ago (Argiles et al. 1998, Tozawa et al. 1999, Sposito
et al. 2000). Our previous study indicated that this phenomenon also existed in patients undergoing peritoneal dialysis (PD)
(Cheng et al. 2006). The potential mechanisms for seasonal
variation of blood pressure might be related to varied peripheral
vascular resistance and extracellular volume with the change of
temperature and humidity across the four seasons (Argiles et al.
1998, Tozawa et al. 1999, Sposito et al. 2000). Indeed, high
temperature could result in vasodilatation and the increase of
water loss by transpiration and perspiration. However, whether
or not the seasonal variation of blood pressure can be reduced
through a given intervention is unknown.
Nurses play an important role in improving quality of life and
outcome of patients with chronic disease, including maintenance dialysis (Keleher et al. 2009, Sutherland & Hayter
2009). In our PD unit, primary nurses actively took part in the
education, counselling and in treatment of PD patients. Based
on the benefits of nursing care in blood pressure control in the
general population (McLean et al. 2008, Carter et al. 2009),
we hypothesized that education on volume control, home
blood pressure monitoring and intensified antihypertensive
treatment through a programme of intensive nursing care could
reduce the seasonal variation of blood pressure in patients on
PD. We aimed to determine the effectiveness of intensive
nursing care on this issue through this study.

The study
Aim
This study was designed to explore the effectiveness of
intensive nursing care in reducing the seasonal pattern of
blood pressure in patients on PD.

Design
This is an interventional cohort study with a pre-test and
post-test.

Participants
Participants were recruited from the PD unit of a University
Hospital in Beijing. Inclusion criteria included patients who
1268

were 18 years of age or older and had been on PD for more

than 3 months. Patients with active inflammatory, infectious
diseases and cancer were excluded from the study. All the
participants were willing to visit us at 1-month interval. All
participants were provided with lactate-buffered glucose
dialysate, twin-bag connection system (Baxter Healthcare,
Guangzhou, China) and treated with continuous ambulatory
peritoneal dialysis (CAPD). Written informed consent was
obtained from each patient.

Interventions
We implemented a programme of intensive nursing care in
participants starting from December 2006. This programme
consisted of education on volume control, home monitoring
blood pressure and intensified antihypertensive treatment.
Participants and their carers were asked to participate in a
meeting organized by primary nurses where the educational
focus was on volume control. The contents of education
referred to: (1) the causes and consequences of hypertension;
(2) Correct measurement of blood pressure (Alpert et al.
2006); (3) the causes and methods of restricting fluid and
sodium intake. A daily intake of no more than 23 g per day
of sodium had been recommended by European and
International Society of Renal Nutrition and Metabolism
for dialysis patients (Fouque et al. 2007, 2008). Each
patient was asked to measure the amount of added salt
using a 1 g or 2 g-size salt spoon and soy sauce using 5 mLsize cup. Participants were asked to avoid processed foods
and eating out since the amount of hidden salt was
unknown. Participants were taught to check and document
the amount of salt labelled on snack or canned foods.
Participants ate foods separately from family members to
ascertain how much salt they consumed (Dong et al. 2010).
(4) Attention to fluid and sodium removal with the loss of
residual renal function.
The home-monitoring plan for blood pressure had an aim
to record Participants blood pressure four times per day, i.e.
morning (before using drugs), noon, afternoon and night
(after using drugs) for 3 days immediately before the monthly
clinic visits.
Participants and their carers were trained to measure blood
pressure and record all the readings. The primary nurses
would remind them to bring the records the day before the
clinical visits.
The intensified antihypertensive treatment was based on
the home records for blood pressure. This helped a
physician adjust the dialysis prescription and antihypertensive medications on clinical day. After that, primary nurses
would call their participants to determine the compliance to
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JAN: ORIGINAL RESEARCH

dialysis and antihypertensive treatment. The first call was

conducted within 72 hours after clinical visits and then
performed every week till the next visit. In the follow-up
call, the primary nurse checked and reinforced the patients
behaviour in volume restriction and blood pressure monitoring, identified any problems met by the patient including
side effects of antihypertensive agents, and discussed with
the patient on any possible management options using
negotiating care strategy. If needed, the primary nurse
would consult with a physician for further adjustment in
prescription.

Data collection
The demographic and biochemical data were collected at
baseline. The assessments of clinical blood pressure and
antihypertensive agents were recorded at 1-month intervals.
The values of these assessments were averaged over 3
monthly visits to represent the seasonal values, that is, winter
(DecemberFebruary), Spring (MarchMay), Summer (June
August) and Autumn (SeptemberNovember). The fluid and
solute removal were regularly evaluated at the end of each
season and represented as seasonal values.
Demographic and biochemical data
Demographic information was collected at the start of
study including age, gender, body mass index and dialysis
duration. Biochemical parameters including haemoglobin,
serum albumin, blood urea nitrogen, and serum creatinine
were examined using an automatic Hitachi chemistry analyzer.
Clinical blood pressure and antihypertensive agents
Participants took usual antihypertensive medications in the
morning of each clinical visit. A skilful nurse measured
patients brachial blood pressures with a mercury sphygmomanometer in a sitting position after resting for at least
5 minutes in a quiet and peaceful room (Alpert et al. 2006).
Measurements for systolic blood pressure (SBP) and diastolic
blood pressure (DBP) were performed. Measurements were
performed twice at 5-minute interval and thus calculated as
an average of the SBP/DBP of the two readings. The dose of
antihypertensive drugs was quantified by the Defined Daily
Dose (DDD) developed by the World Health Organization
(WHO 2009).
Fluid and solute removal, residual renal function
The 24-hour urine was collected 1 day before clinical visit.
The sum of the 24-hour urine and 24-hour ultrafiltration was
calculated as total fluid removal. The sodium levels in
 2011 Blackwell Publishing Ltd

Intensive nursing care and seasonal variation of blood pressure

24-hour urine and 24-hour dialysate was simultaneously

examined using an automatic Hitachi chemistry analyzer.
Total sodium removal was the sum of urinary and dialysate
sodium removal. Urinary sodium removal was the 24-hour
urine volume multiplied by sodium concentration. Dialysate
sodium removal was the sodium content in drained dialysate
minus sodium content in infused dialysate. Total Kt/V
including peritoneal and renal Kt/V, and total creatinine
clearance (Ccr) including peritoneal and renal Ccr were calculated using standard methods. The distribution volume of
urea (V), which is generally assumed to be equal to total body
water, was calculated using the Watson equation. Residual
renal function (RRF) was estimated using the average renal
clearance of urea and creatinine.
Temperature and humidity data
The daily outdoor temperature and humidity was obtained
from the Beijing Weather Bureau. The mean temperature for
four seasons was calculated from daily records.

Ethical considerations
The study was approved by the appropriate Medical Ethical
Committee.

Data analysis
Statistical analysis was performed using a SPSS software
package (version 13.0; SPSS, Chicago, IL, USA). Parametric
data were presented as mean (standard deviation). Nonparametric data were presented as median values with inter
quartile range. The changes in blood pressure, sodium intake,
fluid and sodium removal, doses of antihypertensive agents
across the four seasons, respectively, in 2006 and 2007 were
analysed by using repeated-measure analysis in Linear Mixed
Models. Age, gender and dialysis duration were adjusted as
model covariates. The measurements for variables in different
seasons within 1 year were compared by paired-samples t-test
or Wilcoxon signed rank test as appropriate. All the reported
P values were two-tailed, and statistical significance level was
set at 005.

Results
Baseline characteristics and clinical data
During the enrolment period, 91 patients who failed to meet
the inclusion criteria were excluded, 119 patients met the
eligibility criteria and were recruited into follow-up assessments between Dec, 2005 and Nov, 2006. During the
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L. Quan et al.

following 2 years, 43 of 119 patients were excluded. Of

these, 9 were lost to follow-up, 34 discontinued due to death,
renal transplantation or transferring to haemodialysis.
Finally, 76 participants completed the protocol and were
included in the analysis (Figure 1), with a mean age of 606
(137) years, dialysis duration of 232 (172) months and
body mass index of 228 (323) kg/m2. The baseline characteristics are shown in Table 1.

The climate data

Beijing has a typical northern hemisphere climate. The mean
temperature, humidity and rainfall across four seasons
between 2006 and 2007 are shown in Table 2.

Compliance with intensive nursing care

All the participants received our education on volume control
and regularly visited us. Only 70% of our participants
monitored blood pressure at home as requested. In terms of
intensified antihypertensive treatment, all the participants
were followed up by their primary nurses on the phone to
make sure the implementation of dialysis prescription and
antihypertensive treatment after regular clinical visit but no
compliance data were collected.

Seasonal variation of blood pressure, total fluid and

sodium removal, and DDDs in 2006
In 2006, there were important seasonal variations in SBP and
DBP across four seasons (P < 0001) (Figures 2 and 3). For
SBP, mean peak values of 1391 (186) mmHg occurred in the
winter, and nadir values of 1257 (195) mmHg during the
summer. For DBP, mean peak values were 784 (113) mmHg
in autumn, and nadir values 725 (108) mmHg in summer

Table 1 The baseline characteristic and clinical data in 76 patients

on peritoneal dialysis
Variables

Total (n = 76)

Age, years
Gender, male%
Height, cm
Weight, kg
Body mass index, kg/m2
Dialysis duration, months
Haemoglobin, g/L
Albumin, g/L
Urea, mmol/L
Creatinine, lmol/L
Total, Kt/V
Total Ccr, l/w/173 m2
Residual renal function, mL/min

606
26,
161
591
228
232
1172
378
218
7964
168
552
224

(137)
342
(76)
(104)
(32)
(172)
(131)
(30)
(45)
(2617)
(147194)
(461696)
(015424)

Figure 1 The study flow chart.

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JAN: ORIGINAL RESEARCH

Intensive nursing care and seasonal variation of blood pressure

Table 2 The mean temperature, humidity and rainfall of four seasons in Beijing between 2006 and 2007

Month

Season

Dec, 2005Feb,
2006
Mar, 2006May,
2006
Jun, 2006Aug,
2006
Sept, 2006Nov,
2006
Dec, 2006Feb,
2007
Mar, 2007May,
2007
Jun, 2007Aug,
2007
Sept, 2007Nov,
2007

Winter

Temperature
(C)
177

Humidity
(%)

Rainfall
(mm)

45

24

Spring

139

40

171

Summer

261

65

792

Autumn

148

56

657

Winter

04

467

30

Spring

147

427

313

Summer

266

653

886

Autumn

188

607

1037

(Table 3). The variation in SBP and DBP (calculated as the

highest record minus the lowest record in summer) was 134
and 59 mmHg, respectively. As reported in previous studies,
there was an inverse relationship between temperature and
blood pressure. There were no seasonal patterns of total fluid
and sodium removal throughout this year with 071 and 075
of P values, respectively (Table 3).

Seasonal variation of blood pressure, total fluid and

sodium removal and DDDs in 2007
After intensive nursing care was implemented, the seasonal
variation of blood pressure changed. The SBP did not change
significantly across seasons (P = 026) (Figure 4, Table 4).
The seasonal variation of DBP still occurred, with the highest
level of 802 (131) mmHg and lowest level of 759
(129) mmHg (Figure 5, Table 4). However, the differences
in DBP decreased to 43 mmHg from 49 mmHg. Meanwhile,
the DDDs of antihypertensive agents significantly decreased
in accordance with decreased blood pressure across seasons
(P = 005), with the highest level of 100 (025) in winter
compared to summer and autumn. There were no seasonal
patterns of total fluid (P = 099) and sodium removal
(P = 063) throughout the year.

Discussion

Figure 2 Seasonal variation of systolic blood pressure in 76 patients

on peritoneal dialysis between Winter, 2005 and Autumn, 2006.

Figure 3 Seasonal variation of diastolic blood pressure in 76

patients on peritoneal dialysis between Winter, 2005 and Autumn,
2006.
 2011 Blackwell Publishing Ltd

Our results showed that blood pressure varied throughout

2006, following a seasonality pattern as reported in previous
studies (Argiles et al. 1998, Tozawa et al. 1999, Sposito et al.
2000, Cheng et al. 2006). After the programme of intensive
nursing care was implemented, the seasonal variation of SBP
disappeared. Although DBP still varied across seasons, the
differences between the highest and lowest values reduced. As
far as we know, this is the first study to explore the
effectiveness of a given intervention in the seasonal variation
of blood pressure.
It is well known that the incidence and mortality rate of
cardiovascular disease is greater in winter than in summer in
the general population (Shinkawa et al. 1990, Douglas et al.
1991, Kinjo et al. 1991) and dialysis patients (Iseki et al.
1996), which is partly explained by seasonal variations of
blood pressure (Boulay et al. 1999, Manfredini et al. 1999,
Crawford et al. 2003). With the change of seasons, variation of
temperature and humidity may result in varied extent of
vasodilatation and water loss by transpiration and perspiration, which correlates to seasonal variation of blood pressure.
Previous studies have shown that hydration status estimated by
body weight or intradialytic weight gain was directly associated with increased blood pressure in winter months (Tozawa
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L. Quan et al.

Table 3 Repeated measurements for blood pressure, total fluid and sodium removal and doses of antihypertensive agents in 76 patients on
peritoneal dialysis between Winter, 2005 and Autumn, 2006
Variables

Winter

Spring

Summer

Autumn

SBP, mmHg
DBP, mmHg
Antihypertensive agents, DDDs
Total fluid removal, mg
Total sodium removal, mg

1391
773
133
1050
2185

137
758
133
1010
2280

1257
725
100
1100
2535

1322
784
100
1000
2490

(186)
(120)
(001272)
(7711285)
(16073002)

(213)
(126)
(004300)
(8001265)
(17103110)

(195)*
(108)*
(0267)
(7771307)
(17073221)

(189)
(113)
(0267)
(7901300)
(19103220)

P value
<0001
<0001
062
071
075

SBP, systolic blood pressure; DBP, diastolic blood pressure; DDDs, defined daily doses.
*P < 0001 compared to winter, spring and autumn, respectively; P < 001 or 005 compared to winter, spring and summer, respectively;

P < 0001 indicating a longitudinal change across four seasons.

Figure 4 Seasonal variation of systolic blood pressure in 76 patients

on peritoneal dialysis between Winter, 2006 and Autumn, 2007.

et al. 1999, Sposito et al. 2000, Argiles et al. 2004). It was

suspected that better volume control could be achieved through
the strengthened education and counselling on fluid and
sodium restriction (Hwang et al. 2007, Woods et al. 2008).
However, one previous study by us reported that the change in
extracellular weight was not seasonal, suggesting other mechanisms such as total peripheral resistance might play an
important role in the seasonal variation of blood pressure
(Cheng et al. 2006). Recently, another group from Beijing
further indicated that seasonal variation of blood pressure also

Figure 5 Seasonal variation of diastolic blood pressure in 76

patients on peritoneal dialysis between Winter, 2006 and Autumn,
2007.
existed in patients with chronic kidney disease and had no
correlation with the change of body weight (Bi et al. 2010).
Therefore, not only volume control but also antihypertensive
treatment was stressed in the programme of intensive nursing
care. As shown in our study, intensified antihypertensive
treatment actually rely on home blood pressure monitoring and
intensive telephone follow-up by nurses.
The DDDs values were highest in winter 2006 and then
decreased gradually until they reached its lowest level in

Table 4 Repeated measurements for blood pressure, total fluid and sodium removal and doses of antihypertensive agents in 76 patients on
peritoneal dialysis between Winter, 2006 and Autumn, 2007
Variables

Winter

Spring

Summer

Autumn

P value

SBP, mmHg
DBP, mmHg
Antihypertensive agents, DDDs
Total fluid removal, mg
Total sodium removal, mg

1308
802
100
1083
2790

1267
783
067
1030
2585

1259
759
060
1100
2800

1259
760
069
1050
2665

026
002
005
099
053

(214)
(131)
(0250)
(7501300)
(19673335)

(221)
(133)
(0240)
(8551295)
(20603430)

(216)
(129)*
(0233)
(7401375)
(20103565)

(199)
(123)
(0254)
(7881327)
(17753220)

SBP, systolic blood pressure; DBP, diastolic blood pressure; DDDs, defined daily doses.
*P < 0001 compared to winter and spring, respectively; P < 0001 compared to winter; P < 005 compared to summer and autumn;

P < 005 indicating a longitudinal change across four seasons.

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JAN: ORIGINAL RESEARCH

What is already known about this topic

Hypertension is a major risk factor for cardiovascular
events in the general population and in patients with
end stage renal disease.
The seasonal variation of blood pressure has been
reported to be a common phenomenon in patients on
dialysis.
There have been convincing benefits of nursing care in
blood pressure control in the general population.

What this paper adds

The intensive nursing care performed by us consisted of
education on volume control, home blood pressure
monitoring and intensified antihypertensive treatment.
We add new evidence showing the benefits of intensive
nursing care in reducing seasonal variation of blood
pressure in patients on peritoneal dialysis.

Implications for practice and/or policy

The programme of intensive nursing care is able to offer
support to patients in dealing with exacerbated
hypertension in cold seasons.
Nurses, as one of main healthcare professionals, should
be encouraged to play important roles in caring patients
on dialysis.

autumn, which was in accordance with the decreased blood

pressure during 2007. Contrarily, blood pressure represented
a seasonal variation during 2006 but DDDs of antihypertensive agents did not vary during this time period. This result
supported that implementation of intensified antihypertensive
treatment based on home blood pressure monitoring. To
date, home blood pressure monitoring has been considered as
a better predictor of future cardiovascular risk than office
blood pressure (Fagard et al. 2005, Agarwal & Andersen
2006). It was also shown that home blood pressure monitoring could improve blood pressure control, reducing costs
of health care in the general population (Cappuccio et al.
2004, McManus et al. 2005). We need more evidences
showing the benefits of home blood pressure monitoring in
dialysis population.
At the same time, this data verified again the effectiveness
of nurse-centred interventions, which have strengthened the
treatment and management of chronic disease, especially
hypertension in recent years (McLean et al. 2008, Carter
 2011 Blackwell Publishing Ltd

Intensive nursing care and seasonal variation of blood pressure

et al. 2009, Keleher et al. 2009, Sutherland & Hayter 2009).

Of note, the nurse-initiated telephone follow-up, as a critical
part of integrated care in our unit, has shown its benefits in
achieving a comparable survival rate in patients who contact
doctors less (Xu et al. 2009). Recently, an article from Hong
Kong also indicated that nurse-led case management programme was particularly useful for enhancing PD patients
well-being (Chow & Wong 2010). Nurses, as one of the main
healthcare professionals, are encouraged to be involved in
caring more patients with chronic condition.
Overall, our data indicated that intensive nursing care
could decrease variation in blood pressure, from 134 to
49 mmHg of variation in SBP, and from 59 to 43 mmHg of
variation in DBP. As reported in a large cohort study, each
10-mmHg decrease in home SBP decreased the risk of a
cardiovascular event by 172% and each 5-mmHg decrease in
home DBP decreased that risk by 117% (Bobrie et al. 2004).
Whether or not the decreased seasonal variation of blood
pressure would decrease the incidence of cardiovascular
events and death in cold seasons in dialysis population needs
to be clarified. In addition, blood pressure did not vary
seasonally in a North American haemodialysis sample (Fine
2000). The variation seemed more obvious in tropical and
subtropical climates (Argiles et al. 1998, Tozawa et al. 1999,
Sposito et al. 2000, Cheng et al. 2006), suggesting that
clinicians in these climates should explore more interventions
to prevent the increased blood pressure in cold seasons.
This study has several strengths. To our knowledge, this is
the first study to verify that intensive nursing care could
reduce the seasonal variation of blood pressure. In addition,
participants were thoroughly examined with fluid and
sodium removal, and doses of antihypertensive agents during
the follow-up, which gave us a unique opportunity to
determine the longitudinal change of these variables across
the seasons.
We also realize the limitations of this study. The dietary
recall of sodium intake is an important covariate but not
analysed in this study because they might be underestimated.
Neither did we collect volume data during the follow-up,
which should have provided more potential explanations in
reducing the seasonal variation of blood pressure. More
studies designed with a series measurement of volume status
are needed in the future. Only 76 of 119 enrolled participants were included in the final analysis. We realized that
those excluded from the analysis might have the greatest
variation, which would make our conclusion less compelling.
Also, the relatively small size and single-centre designed
property limited robust conclusion on the generalizable
nature of the effective intensive nursing care demonstrated
in this study.
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L. Quan et al.

Conclusion
Our results indicated that intensive nursing care could reduce
the seasonal variation of blood pressure in patients on PD.
Whether or not this benefit has the long-term effect on
mortality and hospitalization needs to be determined in the
future. Nurses, as one of the main healthcare professionals,
should be encouraged to play their important roles in caring
patients on dialysis.

Acknowledgements
The authors express their appreciation to the patients and
staff of peritoneal dialysis centre of first hospital, Peking
University for their participation in the study.

Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.

Conflict of interest
No conflict of interest has been declared by the authors.

Author contributions
JD and LZ were responsible for the study conception and
design. LQ and YL performed the data collection. JD
performed the data analysis. LQ, JD, YL and LZ were
responsible for the drafting of the manuscript. LQ , JD, YL
and LZ made critical revisions to the paper for important
intellectual content. LZ supervised the study.

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