What is an acceptable blood pressure target for a patient with Chronic Kidney Disease (CKD) stage 5 on dialysis?

Blood Pressure Targets for CKD Stage 5 Patients on Dialysis

For patients with CKD stage 5 on hemodialysis, target a pre-dialysis blood pressure of <140/90 mm Hg and post-dialysis blood pressure of <130/80 mm Hg. 1

Why These Targets Apply to Dialysis Patients

The KDIGO 2021 guideline explicitly states that its systolic blood pressure target of <120 mm Hg does not apply to patients receiving dialysis. 2 This exclusion is critical because:

• Dialysis patients were systematically excluded from SPRINT, the primary trial supporting the <120 mm Hg target 2
• The relationship between blood pressure and mortality in dialysis patients follows a U-shaped curve, where both very low (<120 mm Hg pre-dialysis) and very high (>180 mm Hg pre-dialysis) systolic pressures associate with increased mortality risk 1
• Applying aggressive targets risks catastrophic complications including hypoperfusion, acute kidney injury, falls, and fractures in this vulnerable population 3

Practical Implementation Considerations

Measurement timing matters critically in dialysis patients:

• Pre-dialysis measurements should be <140/90 mm Hg 1
• Post-dialysis measurements should be <130/80 mm Hg 1
• Out-of-dialysis center measurements predict left ventricular hypertrophy and mortality better than in-center measurements 1

These targets should only be pursued if the patient tolerates them without:

• Substantial orthostatic hypotension 1
• Significant symptomatic intradialytic hypotension 1
• Centers achieving better post-dialysis blood pressure control experience significantly more intradialytic hypotension requiring fluid resuscitation 4

Medication Selection

First-line therapy should be ACE inhibitors or ARBs because they provide:

• Greater regression of left ventricular hypertrophy 1
• Reduced sympathetic nervous system activity 1
• Decreased pulse wave velocity 1
• Possible improvement in endothelial function 1

Beta-blockers should be preferred in patients with:

• Prior myocardial infarction 1
• Established coronary artery disease 1

Volume Management is Foundational

Blood pressure control in dialysis patients requires addressing volume status, not just medications:

• Continuous emphasis on salt restriction is integral to management 1
• Achieving dry weight and reducing extracellular volume should be pursued, though this is difficult to monitor and may not be effective in all patients 1

Common Pitfalls to Avoid

Never apply the <120 mm Hg target to dialysis patients - this population faces increased risks of adverse events and was explicitly excluded from supporting evidence 3

Avoid excessive diastolic blood pressure lowering (<70 mm Hg) - this increases cardiovascular risk in CKD patients 3

Do not ignore intradialytic hypotension - achieving tighter post-dialysis targets significantly increases symptomatic hypotension requiring intervention 4