How to manage intradialytic hypertension?

Management of Intradialytic Hypertension

Immediately initiate out-of-unit blood pressure monitoring to assess true interdialytic burden and aggressively challenge dry weight downward, as volume overload is the primary driver of intradialytic hypertension and must be addressed before considering pharmacological interventions. 1

Definition and Clinical Significance

• Intradialytic hypertension is defined as a systolic blood pressure increase of >10 mm Hg from pre- to post-dialysis, affecting 5-15% of hemodialysis patients. 1, 2
• This pattern is independently associated with increased hospitalization and mortality risk comparable to severe intradialytic hypotension. 1, 3
• Patients with intradialytic hypertension are more chronically volume overloaded compared to other hemodialysis patients and have intradialytic vascular resistance surges that explain the BP increase during dialysis. 4, 5

Algorithmic Management Approach

Step 1: Volume Control (First-Line Intervention)

Volume control is the cornerstone of management and must be prioritized before any other intervention. 1

• Aggressively challenge and reduce dry weight through sequential reductions of 0.2-0.5 kg per session until intradialytic hypertension resolves or clinical signs of volume depletion appear. 1
• Lower dialysate sodium concentration to reduce sodium loading and improve volume control. 1, 4
• Optimize ultrafiltration adequacy by ensuring adequate fluid removal to achieve true dry weight. 1
• Implement dietary sodium restriction to 2-3 g/day with regular dietitian counseling to reduce interdialytic fluid accumulation. 1

Step 2: Dialysis Prescription Modifications

• Consider longer or more frequent dialysis sessions (>4 hours or >3 times per week) to achieve better volume control and reduce per-session ultrafiltration requirements. 1
• Avoid high-calcium dialysate as it may contribute to intradialytic hypertension. 3
• Ensure adequate sodium solute removal during hemodialysis to prevent sodium accumulation. 3

Step 3: Medication Optimization

Only after optimizing volume control should pharmacological interventions be considered. 1

• Prioritize nondialyzable antihypertensive agents, particularly beta-blockers with vasodilatory properties (such as carvedilol), which effectively target sympathetic nervous system overactivity and endothelial dysfunction. 1, 2, 4
• Consider ACE inhibitors or angiotensin receptor blockers to inhibit the renin-angiotensin-aldosterone system, which is often overactive in intradialytic hypertension. 1, 3
• Administer antihypertensive medications preferentially at night to reduce nocturnal blood pressure surge and minimize intradialytic hypotension risk. 1
• Avoid dialyzable antihypertensive medications (such as metoprolol) as they are removed during dialysis and may cause rebound effects. 3

Pathophysiologic Mechanisms to Target

• Volume and sodium overload is the most consistent finding and should be the primary therapeutic target. 2, 4, 5
• Sympathetic nervous system overactivity contributes to vascular resistance surges during dialysis. 2, 4
• Renin-angiotensin-aldosterone system activation perpetuates hypertension and should be pharmacologically inhibited. 2, 4
• Endothelial dysfunction and arterial stiffness may be targeted with vasodilatory beta-blockers. 2, 4
• Acute intradialytic changes in endothelial cell function may involve endothelin-1 or other vasoconstrictive peptides. 4, 3

Monitoring and Follow-Up

• Reassess blood pressure response after each intervention using both dialysis unit measurements and out-of-unit monitoring (home BP or ambulatory BP monitoring). 1
• Continue dry weight challenges until intradialytic blood pressure pattern normalizes or clinical signs of volume depletion appear (persistent hypotension despite adequate nutrition, symptomatic hypotension, cramping). 1
• Monitor for signs of overaggressive volume removal, including intradialytic hypotension, cramping, or symptoms of hypovolemia. 1

Common Pitfalls and Caveats

• Do not assume all hypertension during dialysis requires antihypertensive medications—volume overload is the primary culprit and must be addressed first. 1, 4
• Avoid using dialyzable antihypertensives as they are removed during dialysis and provide inadequate BP control. 4, 3
• Do not use high-calcium dialysate in patients with intradialytic hypertension as it may worsen the condition. 3
• Recognize that dialysate-to-serum sodium gradients are associated with BP increases during dialysis, making dialysate sodium modification an important intervention. 4
• Understand that intradialytic hypertension identifies patients with persistently elevated interdialytic blood pressure and chronic cardiovascular risk, requiring comprehensive management beyond the dialysis session. 1