From the Guidelines
For an 85-year-old woman with end-stage renal disease (ESRD), the goal blood pressure should generally be below 140/90 mmHg, considering her age and individual factors. This recommendation is based on the most recent guidelines, including the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, which suggest personalized and more lenient systolic BP targets (e.g., <140 mmHg) for patients aged ≥85 years.
When managing blood pressure in elderly ESRD patients, it's crucial to balance the need to prevent cardiovascular complications with the risk of adverse effects from excessive blood pressure lowering. The choice of antihypertensive medication should consider the patient's reduced kidney function, with options such as ACE inhibitors, ARBs, or calcium channel blockers being suitable, as indicated by guidelines for patients with peripheral and aortic diseases 1.
Key considerations in blood pressure management for this patient include:
- Starting with low doses of medication and gradually increasing as needed and tolerated
- Monitoring for orthostatic hypotension, which is common in elderly ESRD patients
- Regular blood pressure monitoring both at home and during dialysis sessions
- Attention to volume status through appropriate dialysis prescription and sodium restriction
- Recognizing that elderly ESRD patients have increased arterial stiffness and may require a more individualized approach to blood pressure management than younger patients.
Given the patient's age and ESRD, a more lenient blood pressure goal may be appropriate to avoid potential harms associated with over-treatment, as suggested by the guidelines 1.
From the FDA Drug Label
The mean baseline blood pressures were 152/82 mmHg for losartan plus conventional antihypertensive therapy and 153/82 mmHg for placebo plus conventional antihypertensive therapy At the end of the study, the mean blood pressures were 143/76 mmHg for the group treated with losartan and 146/77 mmHg for the group treated with placebo.
The goal blood pressure for an 85-year-old woman with ESRD is not directly stated in the provided drug label. However, the label does provide information on the mean blood pressures achieved in the study.
- Mean baseline blood pressure: 152/82 mmHg to 153/82 mmHg
- Mean blood pressure at the end of the study: 143/76 mmHg to 146/77 mmHg Given the information available, a conservative clinical decision would be to aim for a blood pressure similar to that achieved in the study, but it is essential to note that the label does not provide a specific goal blood pressure for this patient population 2.
From the Research
Goal Blood Pressure for an 85-Year-Old Woman with ESRD
- The American College of Cardiology (ACC)/American Heart Association (AHA) 2011 expert consensus document recommends a blood pressure goal of less than 140/90 mmHg in adults aged 60-79 years, and a systolic blood pressure of 140 to 145 mmHg if tolerated in adults aged 80 years and older 3.
- For adults aged 80 years and older, a blood pressure below 150/90 mmHg has been recommended, with a target goal of less than 140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease 3.
- In patients with end-stage renal disease (ESRD), the effective treatment of hypertension is crucial, and drugs that interrupt the renin-angiotensin axis, such as ACE inhibitors and angiotensin antagonists, are generally suggested as agents of choice 4.
- The choice of antihypertensive agent should be based on individual patient characteristics, including the presence of comorbidities such as diabetes mellitus and renal impairment 5.
- Angiotensin II receptor blockers (ARBs) may be preferred over ACE inhibitors in patients with ESRD due to their more favorable adverse effect profile and lack of association with anaphylactoid dialyser reactions 4, 6.