How do you manage hypertension (high blood pressure) during dialysis?

Management of Hypertension During Dialysis

The management of hypertension during dialysis should begin by addressing volume overload through adjusting the dialysis prescription, as volume is the most significant contributor to hypertension in dialysis patients. 1

Initial Assessment and Approach

• Hypertension during dialysis (intradialytic hypertension) is defined as a systolic blood pressure (SBP) rise >10 mm Hg from pre- to post-dialysis, and should prompt a more extensive evaluation of BP and volume management 1
• Evaluate for volume overload as the primary cause of hypertension in dialysis patients 1, 2
• Consider ambulatory or home blood pressure monitoring to accurately determine BP control status and exclude white-coat hypertension 1, 2

Dialysis Prescription Modifications for Hypertension

• Gently probe the prescribed target weight to address volume overload, which is the first step in managing hypertension in hemodialysis patients 1
• Increase treatment time and/or frequency (possibly through home HD or center-based nocturnal HD) to improve volume control 1
• Decrease interdialytic weight gain (IDWG) through dietary sodium restriction (2-3 g/day) and patient education 1, 2
• Improve vascular stability during hemodialysis by optimizing ultrafiltration rate 1
• Consider using lower dialysate sodium concentration, which may be associated with lower IDWG and BP, though this may increase risk of intradialytic hypotension and cramps 1

Pharmacological Management

• If hypertension persists despite optimizing volume status, initiate or adjust antihypertensive medications 1, 2
• Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) should be preferred as they cause greater regression of left ventricular hypertrophy and may improve endothelial function 1, 3
• Beta-blockers are effective for BP control and may decrease mortality and improve left ventricular function in ESRD patients 3, 4
• Consider calcium channel blockers, which are associated with lower total and cardiovascular-specific mortality in hemodialysis patients 3
• Administer antihypertensive drugs preferentially at night to reduce nocturnal BP surge and minimize intradialytic hypotension 1
• Consider the dialyzability of medications when selecting antihypertensive agents; non-dialyzable agents may provide more consistent BP control 1, 3

Cautions and Special Considerations

• ACEIs can cause anaphylactoid reactions in patients dialyzed with high-flux membranes, requiring immediate cessation of dialysis and aggressive therapy 5
• Monitor for hyperkalemia when using ACEIs, ARBs, or non-selective beta-blockers 5, 3
• Be aware that lisinopril and atenolol have prolonged half-lives in ESRD patients due to predominant renal excretion, allowing for thrice-weekly supervised administration after HD 3
• Avoid excessive ultrafiltration that might lead to intradialytic hypotension, which can increase morbidity and mortality 6

Management of Resistant Hypertension in Dialysis

• For patients with resistant hypertension (elevated BP despite ≥3 antihypertensive medications or use of ≥4 antihypertensives), focus on volume control rather than adding more medications 2
• Ensure adequate dialysis time (at least 4 hours) to deliver sufficient dialysis dose and achieve dry weight 2
• Restrict sodium in both diet and dialysate to facilitate achievement of dry weight 2
• Assess medication adherence, as non-adherence is a common cause of apparent treatment resistance 2

Peritoneal Dialysis (PD) Considerations

• For PD patients with hypertension, maximize peritoneal ultrafiltration and urine output to achieve euvolemia 1
• Strategies include shortening dwell time with glucose-based solutions for high transporters, using icodextrin for long dwells, restricting dietary salt, and using diuretics in those with residual kidney function 1
• Consider experimental approaches such as low-sodium dialysate or bimodal solutions with glucose and icodextrin 1

By systematically addressing volume status first and then optimizing pharmacological therapy, hypertension during dialysis can be effectively managed to reduce cardiovascular morbidity and mortality in this high-risk population.