What is a stable blood pressure (BP) goal for a patient with end-stage renal disease (ESRD) on dialysis?

Blood Pressure Goals for a 92-Year-Old on Dialysis

For a 92-year-old patient on dialysis, a predialysis blood pressure goal of <140/90 mmHg and postdialysis goal of <130/80 mmHg is recommended, provided there is no substantial orthostatic hypotension or symptomatic intradialytic hypotension.

Understanding BP Management in Elderly Dialysis Patients

Recommended BP Targets

• The 2005 K/DOQI guidelines recommend a predialysis BP target of <140/90 mmHg and a postdialysis BP target of <130/80 mmHg for hemodialysis patients 1
• These targets should be measured with the patient in a sitting position 1
• For very elderly patients (≥80 years), a slightly higher systolic BP goal of 140-150 mmHg may be more appropriate to avoid adverse events 2, 3

Special Considerations for the Elderly

• Elderly patients are at increased risk for orthostatic hypotension and intradialytic hypotension 1
• Patients with standing systolic BP <110 mmHg should be treated with caution due to risks of hypotension and syncope 1
• A stepped-care approach is preferred over starting with 2-drug therapy in elderly patients 1
• Close monitoring for adverse effects is essential, particularly acute kidney injury, electrolyte abnormalities, and hypotension 1

Evidence Quality and Controversies

• The recommended BP targets for dialysis patients are based largely on expert opinion rather than strong evidence 1
• Most observational data show a "U" or "J"-shaped relationship between BP and mortality in dialysis patients 1
• In the only prospective study performed in dialysis patients, a BP of 140/90 mmHg minimized left ventricular hypertrophy and death 1
• The 2012 KDIGO BP guideline and the ACC/AHA guideline do not recommend specific BP goals for dialysis patients due to lack of evidence 1

BP Measurement Considerations

• There is poor correlation between dialysis clinic BP measurements and mean interdialytic BP assessed using 44-hour ambulatory blood pressure monitoring 1
• Home BP recordings during the interdialytic period may provide more accurate measurements 1
• In patients who have undergone multiple vascular access procedures in both arms, BP should be measured in the thighs or legs using appropriate cuff size and in the supine position 1

Management Approach

Volume Management

• Management of hypertension in dialysis patients requires attention to both fluid status and antihypertensive medications 1
• Strategies to manage fluid status include:
  • Low sodium intake (2-3 g/day) 1
  • Increased ultrafiltration 1
  • Longer dialysis sessions 1
  • More frequent dialysis (>3 treatments per week) 1

Medication Management

• If volume control is insufficient, antihypertensive drugs should be initiated 1
• ACE inhibitors or ARBs are often recommended as first-line agents due to their benefits in reducing left ventricular hypertrophy 1
• Beta-blockers are preferred in patients with coronary artery disease 1
• Calcium channel blockers and alpha-blockers may be needed for adequate control 1
• Consider administering antihypertensive drugs at night to reduce nocturnal BP surge and minimize intradialytic hypotension 1
• Consider the dialyzability of medications when selecting therapy 1

Pitfalls and Caveats

• Excessive BP lowering in elderly dialysis patients can lead to:
  • Orthostatic hypotension 4
  • Intradialytic hypotension 1
  • Increased risk of falls and fractures 2
  • Cerebral hypoperfusion 2
• Erythropoietin therapy can worsen hypertension, particularly in patients with pre-existing hypertension 1
• Achieving BP targets must be balanced against the risk of adverse events, especially in frail elderly patients 4