What vital sign parameter should be used to hold treatment in End-Stage Renal Disease (ESRD) patients?

Vital Sign Parameters for Holding Treatment in ESRD Patients

For patients with End-Stage Renal Disease (ESRD), blood pressure is the primary vital sign parameter that should be used to determine when to hold treatment, with specific thresholds based on the patient's individual cardiovascular risk profile.

Blood Pressure Parameters

Systolic Blood Pressure Thresholds

• Treatment should be held if systolic blood pressure (SBP) is below 120 mmHg, as lower systolic targets may lead to increased cardiovascular events and mortality in ESRD patients 1
• For older ESRD patients (≥65 years), treatment should be held if SBP falls below 130 mmHg to avoid complications 1
• Upper thresholds for holding treatment include SBP >180 mmHg, which may indicate severe hypertension requiring management before proceeding with dialysis 1, 2

Diastolic Blood Pressure Considerations

• Diastolic blood pressure (DBP) <80 mmHg in combination with low systolic pressure should prompt consideration of holding treatment, especially in patients with known cardiovascular disease 1, 3
• Extremely elevated DBP >110 mmHg may also warrant holding treatment until blood pressure is better controlled 2

Special Considerations for Dialysis Patients

Hemodialysis-Specific Parameters

• For patients receiving intensive hemodialysis (short daily or nocturnal), treatment should be held if there are signs of hemodynamic instability, particularly if SBP falls below 100 mmHg during treatment 1, 2
• Intradialytic hypotension (defined as SBP <90 mmHg or a drop of >20 mmHg with symptoms) should prompt immediate intervention and potential termination of the session 2, 4

Peritoneal Dialysis Considerations

• For peritoneal dialysis patients, blood pressure monitoring should focus on home measurements rather than clinic readings to guide treatment decisions 4
• Treatment modifications should be considered if consistent home readings show SBP <110 mmHg or >160 mmHg 4

Monitoring Recommendations

• Blood pressure should be measured at every routine visit and confirmed on a separate day if elevated 1
• Home blood pressure self-monitoring and 24-hour ambulatory blood pressure monitoring provide additional evidence of "white coat" and masked hypertension 1
• For patients with diabetes and ESRD, more stringent monitoring is recommended with treatment adjustments if BP exceeds 140/80 mmHg 1

Common Pitfalls to Avoid

• Avoid attributing all blood pressure elevations to the dialysis procedure without appropriate evaluation 5
• Be cautious about aggressive blood pressure lowering in ESRD patients, as "normal" blood pressure targets from the general population may be associated with higher mortality in dialysis patients (reverse epidemiology) 3
• Don't overlook the importance of volume status assessment when interpreting blood pressure readings in ESRD patients 2, 4

Algorithm for Decision-Making

1. Measure pre-dialysis blood pressure
2. If SBP <120 mmHg or >180 mmHg, consider holding treatment
3. If patient is ≥65 years and SBP <130 mmHg, consider holding treatment
4. Assess for symptoms of hypotension or hypertension
5. Evaluate volume status through physical examination
6. If proceeding with treatment, monitor BP closely during the session
7. Hold or terminate treatment if intradialytic hypotension develops (SBP <90 mmHg or drop >20 mmHg with symptoms)

By following these parameters, clinicians can make appropriate decisions about when to hold treatment for ESRD patients, balancing the risks of dialysis-related complications against the benefits of adequate renal replacement therapy.