How to manage hypertension in a patient with Chronic Kidney Disease (CKD) on maintenance hemodialysis (HD) prior to a dialysis catheter change?

Management of Hypertension in a CKD Patient on Hemodialysis with BP 190/100

For a hemodialysis patient presenting with severe hypertension (BP 190/100), immediate management should focus on volume assessment and gradual blood pressure reduction to prevent cardiovascular complications.

Initial Assessment and Management

• Evaluate volume status as excessive intravascular volume is a major pathogenic factor of hypertension in dialysis patients 1
• Assess for symptoms of end-organ damage (headache, visual changes, chest pain, shortness of breath) 1
• Measure blood pressure according to guidelines: patient seated quietly for at least 5 minutes, feet on floor, arm supported at heart level 1
• Consider that pre-dialysis blood pressure may overestimate true blood pressure by approximately 14/7 mmHg 1

Target Blood Pressure

• For hemodialysis patients, a reasonable goal is predialysis blood pressure of ≤140/90 mmHg measured in the sitting position 1
• This target minimizes the occurrence of left ventricular hypertrophy and death in dialysis patients 1
• Avoid excessive blood pressure reduction as a U-shaped relationship exists between blood pressure and mortality in dialysis patients, with increased risk at both very low and very high levels 1

Treatment Algorithm

First-Line Approach: Volume Management

• Focus on achieving dry weight through ultrafiltration during the dialysis session 1
• Consider extending dialysis time or increasing ultrafiltration rate if clinically appropriate 1
• Emphasize dietary sodium restriction (2 g/day sodium intake) 1
• Monitor for orthostatic hypotension and intradialytic hypotension during treatment 1

Pharmacological Management

If volume management is insufficient:

1. First-line medications: ACE inhibitors or ARBs are preferred as they reduce left ventricular hypertrophy and are associated with decreased mortality in dialysis patients 1

2. Second-line options:

   • Beta-blockers for patients with previous myocardial infarction or established coronary artery disease 1
   • Calcium channel blockers which are associated with decreased total and cardiovascular mortality 1
   • Alpha-adrenergic blockers for resistant hypertension 1

3. For severe hypertension: Consider adding minoxidil if blood pressure remains uncontrolled with multiple agents 1

Important Considerations

• Consider dialyzability of antihypertensive medications when selecting agents 1
• Home blood pressure monitoring or ambulatory blood pressure monitoring provides more accurate assessment of true blood pressure than in-center measurements 1, 2
• More frequent hemodialysis (short daily or nocturnal) may provide better blood pressure control in resistant cases 1, 3
• Evaluate for secondary causes of resistant hypertension if blood pressure remains uncontrolled despite optimal therapy 1

Catheter Change Considerations

• Proceed with catheter change after initiating appropriate blood pressure management 1
• Monitor closely for hemodynamic changes during the procedure 1
• Continue antihypertensive medications perioperatively unless contraindicated 1

Common Pitfalls

• Overly aggressive blood pressure reduction may lead to intradialytic hypotension and adverse outcomes 1, 4
• Failure to recognize the importance of volume control as the primary driver of hypertension in most dialysis patients 1
• Relying solely on pre-dialysis blood pressure measurements which may not accurately reflect true blood pressure burden 1, 2
• Neglecting to consider the dialyzability of antihypertensive medications, which can affect their efficacy 1