Continuing Dialysis with Blood Pressure >180 mmHg
It is generally safe to continue dialysis even when blood pressure exceeds 180 mmHg, as the elevated pressure itself is not an absolute contraindication to proceeding with the session, and in fact, achieving volume control through dialysis is often the primary treatment for this hypertension. 1
Key Decision Points
When to Proceed with Dialysis
- Blood pressure 180-200 mmHg systolic without symptoms of hypertensive emergency can proceed with dialysis, as volume removal is often the underlying solution to the hypertension itself 2, 3
- Exclude hypertensive emergency first - look specifically for acute end-organ damage including encephalopathy, acute heart failure, acute coronary syndrome, or visual changes requiring fundoscopy 1
- The "paradoxical" phenomenon exists where some patients with severe volume overload and cardiac dilation actually experience rising blood pressure during ultrafiltration initially, but ultimately achieve normotension with continued aggressive volume removal 4
When to Exercise Caution or Delay
- BP ≥180/110 mmHg requires evaluation for hypertensive emergency with fundoscopy to assess for papilledema, hemorrhages, or exudates 1
- Symptomatic hypertension (severe headache, visual changes, chest pain, dyspnea) warrants immediate evaluation before proceeding 1
- New-onset severe hypertension in a previously controlled patient should prompt investigation for medication non-adherence, excessive sodium intake, or inadequate achievement of dry weight 2, 5
The Volume-First Approach
Why Dialysis Should Continue
The fundamental pathophysiology of hypertension in dialysis patients is extracellular volume expansion, making ultrafiltration the definitive treatment rather than a contraindication 2, 3, 6
- Antihypertensive medications alone inadequately control BP in hemodialysis patients without addressing volume status 6, 7
- Strict volume control provides optimal blood pressure control often without need for antihypertensive drugs 3
- The relationship between volume and BP may be sigmoidal - blood pressure only rises when physiological autoregulation can no longer compensate for fluid excess 2
The Lag Phenomenon
- Extracellular fluid volume normalizes within weeks, but elevated blood pressure may continue to decrease for 8 months or longer after achieving euvolemia 2
- Do not interpret persistent hypertension during volume removal as treatment failure - continue the volume control strategy 2
Practical Management Algorithm
Immediate Session Management
- Assess for hypertensive emergency - check for symptoms (headache, visual changes, chest pain, altered mental status) 1
- If no emergency signs, proceed with dialysis using standard ultrafiltration goals 2, 3
- Avoid high ultrafiltration rates (>13 mL/kg/hour) which increase risk of intradialytic hypotension and organ ischemia without improving long-term BP control 3
- Consider extending dialysis time to 4+ hours to allow adequate fluid removal at safer rates 5
Intrasession Monitoring
- Monitor for intradialytic hypertension (SBP rise >10 mmHg from pre- to post-dialysis), which suggests inadequate dry weight achievement 1, 2
- Paradoxical BP rise during ultrafiltration in patients with cardiac dilation indicates severe volume overload requiring continued aggressive volume removal 4
- Do not administer saline boluses for mild symptoms if BP remains elevated, as this perpetuates volume overload 2
Long-Term Strategy
Target predialysis BP <140/90 mmHg and postdialysis BP <130/80 mmHg through volume management as primary therapy 1
- Dietary sodium restriction to 2-3 g/day (approximately 5-7.5 g salt) is essential 1, 2
- Gradually reduce postdialysis weight by 0.2-0.5 kg per session until dry weight achieved 2, 3
- Lower dialysate sodium concentration (avoid >140 mmol/L) to facilitate volume removal 1, 2
- Increase dialysis frequency or duration if unable to achieve adequate ultrafiltration in conventional 3x/week schedule 1, 5
Medication Considerations
When Antihypertensives Are Needed
Reserve antihypertensive medications for patients at dry weight with persistent BP >140/90 mmHg 1, 6
- ACE inhibitors or ARBs are first-line agents due to effects on left ventricular hypertrophy regression and cardiovascular protection 1
- Administer antihypertensives at night to reduce nocturnal BP surge and minimize intradialytic hypotension 1
- Consider dialyzability - enalapril and ramipril are removed by dialysis, while benazepril, fosinopril, and ARBs are not 1
Medications to Avoid or Adjust
- Discontinue antihypertensives during volume reduction phase to prevent intradialytic hypotension 2, 3
- Avoid high-dose diuretics as primary therapy - they provide minimal benefit once on dialysis and should not be considered antihypertensive agents 1
Critical Pitfalls to Avoid
Common Errors
- Treating elevated BP with medications instead of addressing volume status - this fails to address the root cause and may cause intradialytic hypotension 3, 6, 5
- Stopping ultrafiltration due to mild symptoms when BP remains elevated - this perpetuates volume overload 2
- Using high dialysate sodium (>145 mmol/L) or sodium profiling - these worsen hypertension and thirst 1, 2
- Administering saline for hypotensive symptoms in volume-overloaded patients - this expands extracellular volume further 2
Safety Concerns That Are Actually Related to Ultrafiltration Rate, Not Volume Removal
High ultrafiltration rate (>13 mL/kg/hour) rather than volume reduction itself causes complications including intradialytic hypotension, organ ischemia, residual renal function loss, and access thrombosis 3
- Solution: extend dialysis time or increase frequency to achieve same volume removal at lower rates 3, 5
- The cardiovascular benefits of achieving euvolemia (LVH regression, heart failure prevention, reduced mortality) outweigh risks when volume removal is done gradually 3
Special Populations
Patients with Cardiac Dilation
- Paradoxical BP rise during ultrafiltration indicates severe volume overload requiring continued aggressive fluid removal 4
- Echocardiographic monitoring shows progressive improvement in cardiac dimensions, ejection fraction, and valvular regurgitation with sustained volume control 4
- Mean weight reduction of 6.7 kg achieved normotension in patients with this phenomenon 4