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  • Review Article
  • Published:

Epidemiology, diagnosis and management of hypertension among patients on chronic dialysis

Nature Reviews Nephrology volume 12, pages 636–647 (2016)Cite this article

Subjects

Key Points

  • Contrary to the reverse epidemiology of hypertension as assessed by peridialytic blood pressure (BP) recordings, interdialytic BP assessed either by home or ambulatory BP monitoring is linearly associated with an increased risk of all-cause and cardiovascular mortality

  • Routine BP recordings obtained before or after dialysis sessions display high variability, poor reproducibility and provide inaccurate estimates of the interdialytic BP burden; out-of-dialysis BP monitoring improves the accuracy of hypertension diagnoses among dialysis patients

  • Rather than initiating or intensifying antihypertensive drug therapy, management of hypertension among dialysis patients should initially involve strict control of sodium and volume excess

  • Restricting dietary sodium intake, individualizing dialysate sodium, avoiding use of short dialysis sessions and probing of dry weight represent the major non-pharmacological interventions to control volume excess

  • Antihypertensive drug therapy is necessary when BP remains uncontrolled despite the optimal management of volume; with the exception of diuretics, all major antihypertensive classes are useful in treating hypertension in patients on dialysis

  • Choice of the appropriate antihypertensive regimen should be individualized and based on the BP-lowering efficacy, cardioprotective properties, intradialytic and interdialytic pharmacokinetics and adverse-effect profiles of the agents; β-blockers, particularly atenolol, or long-acting calcium-channel blockers are reasonable options

Abstract

The diagnosis and management of hypertension among patients on chronic dialysis is challenging. Routine peridialytic blood pressure recordings are unable to accurately diagnose hypertension and stratify cardiovascular risk. By contrast, blood pressure recordings taken outside the dialysis setting exhibit clear prognostic associations with survival and might facilitate the diagnosis and long-term management of hypertension. Once accurately diagnosed, management of hypertension in individuals on chronic dialysis should initially involve non-pharmacological strategies to control volume overload. Accordingly, first-line strategies should focus on achieving dry weight, individualizing dialysate sodium concentrations and ensuring dialysis sessions are at least 4 h in duration. If blood pressure remains unresponsive to volume management strategies, pharmacological treatment is required. The choice of appropriate antihypertensive regimen should be individualized taking into account the efficacy, safety, and pharmacokinetic properties of the antihypertensive medications as well as any comorbid conditions and the overall risk profile of the patient. In contrast to their effects in the general hypertensive population, emerging evidence suggests that β-blockers might offer the greatest cardioprotection in hypertensive patients on dialysis. In this Review, we discuss estimates of the epidemiology of hypertension in the dialysis population as well as the challenges in diagnosing and managing hypertension among these patients.

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Figure 1: Changes in relative plasma volume (RPV) in response to reductions in dry weight in a patient on dialysis.
Figure 2: The effect of dry-weight probing on 44 h ambulatory systolic and diastolic blood pressure among hypertensive patients on dialysis.
Figure 3: Algorithm for the diagnosis and management of hypertension in patients on dialysis.

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Acknowledgements

R.A. is supported by NIH 5R01-HL126901 and a grant from VA Merit Review 5I01CX000829-04.

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Authors and Affiliations

  1. Division of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, Thessaloniki, GR54006, Greece

    Panagiotis I. Georgianos

  2. Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Mail Code: 111N, 1481 West 10th Street, Indianapolis, 46202–2884, USA

    Rajiv Agarwal

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  1. Panagiotis I. Georgianos
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Contributions

P.I.G. drafted the first version of the article under the supervision of R.A. R.A. revised the manuscript and modified it significantly before submission.

Corresponding author

Correspondence to Rajiv Agarwal.

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Competing interests

R.A. has consulted for Abbvie, Amgen, Astra Zeneca, Bayer, Boehringer Ingelheim, Celgene, Daiichi Sankyo Inc, Eli Lilly, Gilead, Glaxosmithkine, Johnson & Johnson, Merck, Novartis, Sandoz, Relypsa, and ZS Pharma. P.I.G. declares no competing interests.

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Glossary

Peridialytic BP

Blood pressure recordings obtained by the dialysis-unit staff shortly before and/or after the dialysis session.

Interdialytic BP

Blood pressure recordings obtained outside of the dialysis unit either with the use of home or ambulatory blood pressure monitoring.

Ambulatory BP monitoring

An automated method to measure blood pressure that uses an oscillometric device to typically record blood pressure 2–3 times per hour over an entire interdialytic interval. Averaged readings are considered the reference standard for true blood pressure.

Intradialytic BP

Blood pressure recordings obtained typically every 30 minutes during dialysis using an automated cuff attached to the dialysis machine.

Dry-weight probing

The iterative process of gently and gradually reducing postdialysis weight by setting the ultrafiltration goal to just a little below the previously achieved postdialysis weight; this process requires the assessment of intradialytic and interdialytic symptoms and signs of hypervolaemia or hypovolaemia.

Dry weight

The lowest tolerated postdialysis weight achieved at which minimal signs or symptoms of either hypovolaemia or hypervolaemia exist

Sodium-profiling dialysis

Time-dependent modification of the sodium concentration in the dialysate over the course of the dialysis session.

RPV monitoring

Continuous noninvasive measurement of the haematocrit level during dialysis using photo-optical technology to assess changes in intravascular blood volume with ultrafiltration.

Bioelectrical impedence analysis

A non-invasive method to estimate body composition and the relative pool sizes of total body water, extracellular fluid volume and intracellular fluid volume.

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Georgianos, P., Agarwal, R. Epidemiology, diagnosis and management of hypertension among patients on chronic dialysis. Nat Rev Nephrol 12, 636–647 (2016). https://doi.org/10.1038/nrneph.2016.129

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