From the Guidelines
Patients with End-Stage Renal Disease (ESRD) on Hemodialysis (HD) have difficulty controlling hypertension primarily due to volume overload, which is the major pathogenic factor of hypertension in these patients. This is supported by the most recent and highest quality study, which emphasizes the importance of addressing volume overload in the management of hypertension in HD patients 1. The study suggests that options for managing volume overload include gently probing the prescribed target weight, increasing treatment time and/or frequency, decreasing interdialytic weight gain (IDWG), and improving vascular stability during HD.
Key factors contributing to difficult-to-control blood pressure in ESRD patients on HD include:
- Volume overload, which leads to increased blood volume and consequently elevated blood pressure
- Dysregulation of the renin-angiotensin-aldosterone system, contributing to vasoconstriction and sodium retention
- Arterial stiffness, common in these patients due to vascular calcification and chronic inflammation, reducing the blood vessels' ability to accommodate pressure changes
- Sympathetic nervous system overactivity, further exacerbating hypertension by increasing heart rate and peripheral vascular resistance
Management of hypertension in ESRD patients on HD typically involves a combination of:
- Careful dry weight assessment
- Ultrafiltration during dialysis
- Antihypertensive medications, such as calcium channel blockers, beta-blockers, and vasodilators
- Dietary sodium restriction (less than 2g daily)
- Interdialytic weight gain limitation (ideally below 2-3kg)
It is essential to note that the most recent study 1 provides the strongest evidence for the management of hypertension in HD patients, and its recommendations should be prioritized in clinical practice. Additionally, the study highlights the importance of individualized care and careful monitoring of patients to achieve optimal blood pressure control and reduce the risk of cardiovascular complications.
From the FDA Drug Label
The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]).
The FDA drug label does not answer the question.
From the Research
Factors Contributing to Difficulty in Controlling Hypertension
- Missed dialysis treatments 2
- Intradialytic changes in blood pressure (BP) 2, 3
- Medication removal with dialysis 2, 4
- Poor correlation of BPs obtained in the dialysis unit with those at home and with CV outcomes 2
- Difficulty in determining optimal BP in dialysis patients 3
Pathophysiology of Hypertension in ESRD
- Multifactorial, including volume overload, activation of the renin-angiotensin-aldosterone system, and sympathetic nervous system activation 3, 5
- Associated with increased risk for left ventricular hypertrophy, coronary artery disease, congestive heart failure, cerebrovascular complications, and mortality 2, 3, 5
Treatment Options for Hypertension in ESRD
- Control of extracellular volume with ultrafiltration and dietary sodium restriction 2
- Antihypertensive medications, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, and calcium channel blockers 2, 3, 4, 5
- Individualization of therapy, considering patient comorbidities and potential drug interactions 2, 4
- Use of nondialyzable medications to manage intradialytic hypertension 2
- Consideration of thrice-weekly dosing of medication after dialysis to improve BP control 2, 4
Monitoring and Management of Hypertension in ESRD
- Regular home BP monitoring 3
- Yearly echocardiography to assess left ventricular mass and function 3
- Treatment of traditional risk factors for cardiovascular disease 3
- Consideration of interdialytic ambulatory blood pressure monitoring (ABPM) to determine if the patient is hypertensive and to assess changes in BP between day and night 3