Is a Mean Arterial Pressure (MAP) goal of 60 mmHg suitable for a patient on peritoneal dialysis?

Mean Arterial Pressure Goals in Peritoneal Dialysis Patients

A MAP goal of 60 mmHg is too low for most peritoneal dialysis patients, and a target MAP of 65-95 mmHg is more appropriate to reduce mortality risk. 1, 2

Optimal Blood Pressure Targets in Peritoneal Dialysis

Evidence-Based MAP Goals

• Recent guidelines from the American Association for the Study of Liver Diseases (AASLD) indicate that while a MAP target of 60-65 mmHg may be appropriate for certain critically ill patients with vasodilatory shock, this target is not validated for peritoneal dialysis patients 1
• Studies specifically examining peritoneal dialysis patients show a U-shaped relationship between MAP and mortality:
  • MAP below 88-95 mmHg is associated with significantly higher mortality risk 2, 3
  • MAP above 102-120 mmHg also increases mortality risk 2, 3
  • The optimal MAP range appears to be 95-102 mmHg for peritoneal dialysis patients 3

Blood Pressure Variability in Peritoneal Dialysis

• Peritoneal dialysis patients experience less blood pressure variability compared to hemodialysis patients (only about 3 mmHg variation in morning systolic BP over a week) 4
• This relative hemodynamic stability allows for more consistent blood pressure management but still requires appropriate targets

Recommended Approach to Blood Pressure Management

Target Blood Pressure Goals

• For peritoneal dialysis patients, the recommended predialysis blood pressure goal is <140/90 mmHg 5
• This typically corresponds to a MAP of approximately 65-95 mmHg, which is higher than the 60 mmHg mentioned in the question
• Targeting a MAP as low as 60 mmHg could lead to hypoperfusion and increased mortality risk 2, 3

Volume Control as First-Line Strategy

• Volume control through ultrafiltration and sodium restriction should be the first-line approach to blood pressure management 5
• Assessment of dry weight using bioelectrical impedance or clinical parameters (absence of edema, normal heart rate, normal cardiothoracic ratio) is crucial before adjusting medication 4

Medication Management

• If blood pressure remains elevated despite optimal volume status:
  • ACE inhibitors or ARBs are recommended as first-line medications 5
  • Beta-blockers (particularly non-dialyzable options like carvedilol) can be added 5
  • Calcium channel blockers (like amlodipine) may be better tolerated in patients prone to hypotension 5

Special Considerations

Monitoring and Assessment

• Regular home blood pressure monitoring is recommended at least once weekly 4
• Both office and ambulatory blood pressure measurements should be considered, as ambulatory measurements correlate better with left ventricular mass 6
• Fluid status assessment should be performed regularly, as 36.6% of peritoneal dialysis patients may be overhydrated despite meeting standard treatment guidelines 6

Cardiovascular Risk

• Both high MAP (≥120 mmHg) and low MAP (≤95 mmHg) are associated with increased cardiovascular mortality 3
• Elevated pulse pressure (>60 mmHg) is also associated with higher all-cause and cardiovascular mortality in peritoneal dialysis patients 7

In conclusion, while a MAP of 60 mmHg may be acceptable in certain critically ill patients with vasodilatory shock, this target is too low for most peritoneal dialysis patients and could increase mortality risk. A MAP target of 65-95 mmHg is more appropriate based on current evidence.