What is the recommended management for hypertension in patients undergoing ongoing hemodialysis (HD)?

Management of Hypertension in Hemodialysis Patients

The cornerstone of hypertension management in hemodialysis patients is achieving proper volume control through appropriate ultrafiltration, dietary sodium restriction, and optimizing dialysate sodium concentration, followed by judicious use of antihypertensive medications when needed. 1, 2

Blood Pressure Targets and Assessment

• Target predialysis blood pressure should be ≤140/90 mmHg and postdialysis blood pressure ≤130/80 mmHg 1, 2
• Blood pressure should be measured with the patient seated quietly for at least 5 minutes, feet on floor, arm supported at heart level 1, 2
• Home blood pressure monitoring or ambulatory blood pressure monitoring provides more accurate assessment than in-center measurements 1, 3, 4
• Pre-dialysis blood pressure may overestimate true blood pressure by approximately 14/7 mmHg 2
• In patients with multiple vascular access procedures in both arms, measure blood pressure in the thighs or legs using appropriate cuff size 1, 3

Volume Management (First-Line Approach)

• Focus first on achieving dry weight through appropriate ultrafiltration during dialysis sessions 1, 2
• Implement strict dietary sodium restriction (2-3 g/day) with regular dietary counseling 1, 2
• Consider lower dialysate sodium concentrations (around 135 mmol/L rather than 140 mmol/L) 5
• Avoid high dialysate sodium concentration and sodium profiling as these can aggravate thirst, fluid gain, and hypertension 5
• For difficult-to-control hypertension, consider increased ultrafiltration, longer dialysis sessions, or more frequent dialysis (>3 treatments/week) 1, 6

Pharmacological Management (When Volume Control Is Insufficient)

• ACE inhibitors or ARBs are preferred as first-line agents as they:
  • Cause greater regression of left ventricular hypertrophy
  • Reduce sympathetic nerve activity
  • Improve endothelial function and reduce oxidative stress 1, 2, 7
• Beta-blockers are preferred in patients with coronary artery disease or heart failure 1, 3, 7
• Calcium channel blockers have demonstrated efficacy in reducing cardiovascular events 1, 8
• For patients with compliance issues, consider renally eliminated agents (like lisinopril or atenolol) that can be given thrice weekly after dialysis 7

Medication Administration Considerations

• Administer antihypertensive drugs preferentially at night to:
  • Reduce nocturnal blood pressure surge
  • Minimize intradialytic hypotension 1, 2
• Consider the dialyzability of medications when selecting agents 1, 2
• Avoid older antihypertensive agents requiring thrice daily dosing due to high pill burden and risk of noncompliance 7

Special Considerations and Pitfalls

• Monitor for orthostatic hypotension, particularly in elderly patients 1, 3
• Be cautious with excessive blood pressure reduction as a U-shaped relationship exists between blood pressure and mortality in dialysis patients 1, 3, 2
• Evaluate for secondary causes of resistant hypertension if blood pressure remains uncontrolled despite optimal therapy 1, 2
• Don't rely solely on predialysis or postdialysis blood pressure measurements 1, 4
• Don't neglect volume status assessment before initiating or increasing antihypertensive medications 1, 2
• Preserve residual kidney function when possible, as it is an important predictor of patient survival 5

Loop Diuretics

• Large doses of potent loop diuretics (furosemide, bumetanide, torsemide) can be administered to promote sodium and water loss in patients with residual kidney function 5
• However, diuretic use should be approached with caution 5