How to manage intradialytic hypertension in patients with end-stage renal disease (ESRD) undergoing hemodialysis?

Management of Intradialytic Hypertension

When intradialytic hypertension occurs (systolic BP rise >10 mm Hg from pre- to post-dialysis), continue ultrafiltration to achieve the prescribed dry weight target and aggressively challenge dry weight over subsequent sessions, as volume overload is the primary driver and volume removal remains the cornerstone of management even when blood pressure paradoxically rises. 1

Definition and Recognition

• Intradialytic hypertension is defined as a systolic BP increase >10 mm Hg from pre- to post-dialysis, affecting 5-15% of hemodialysis patients 1, 2, 3
• This pattern should prompt extensive evaluation when it occurs in at least 4 of 6 consecutive dialysis treatments 4, 1
• This phenomenon is independently associated with increased hospitalization and mortality risk comparable to severe intradialytic hypotension 1, 2, 3

Immediate Management During the Dialysis Session

• Continue ultrafiltration to achieve the prescribed dry weight target—do not reduce the ultrafiltration rate unless there are signs of acute volume depletion (severe cramping, symptomatic hypotension upon standing, or clinical hypovolemia) 1
• The blood pressure rise during dialysis does not indicate the need to stop or reduce fluid removal in most cases 1
• Only stop dialysis for severe muscle cramping unresponsive to reduced ultrafiltration rate, clinical evidence of acute volume depletion, or other acute complications unrelated to blood pressure 1

Post-Session Algorithmic Management

Step 1: Assess True Blood Pressure Burden

• Immediately initiate out-of-unit blood pressure measurements (home BP monitoring or ambulatory BP monitoring) to assess true interdialytic burden 1
• This distinguishes isolated intradialytic rises from persistently elevated interdialytic hypertension 4, 1

Step 2: Volume Control as Primary Intervention

• Aggressively challenge and reduce dry weight over subsequent sessions, typically over 4-12 weeks, potentially extending to 6-12 months for patients with diabetes or cardiomyopathy 1
• Do not stop the dry weight probing process prematurely—blood pressure may continue to decrease for 8 months or longer after extracellular fluid volume normalizes 1
• Lower dialysate sodium concentration to reduce interdialytic fluid accumulation 1, 2
• Consider longer or more frequent dialysis sessions to achieve better volume control without excessive ultrafiltration rates 1, 2

Step 3: Dietary Sodium Restriction

• Implement strict dietary sodium restriction to 2-3 g/day with regular counseling by dietitians to reduce interdialytic fluid accumulation and allow for more effective volume control 1, 2

Step 4: Medication Optimization

• Prioritize nondialyzable antihypertensive agents, particularly beta-blockers with vasodilatory properties (such as carvedilol) 1, 2
• Add ACE inhibitors or angiotensin receptor blockers to inhibit the renin-angiotensin-aldosterone system 4, 1, 2
• Administer antihypertensive medications preferentially at night to reduce nocturnal blood pressure surge and minimize intradialytic hypotension risk 1
• Avoid dialyzable antihypertensive medications that may be removed during the session 3, 5

Evidence-Based Medication Selection

Beta-Blockers (Preferred First-Line)

• Carvedilol demonstrated lower risk of death and cardiovascular death versus placebo in HD patients with dilated cardiomyopathy 4
• Atenolol showed fewer heart failure hospitalizations compared to lisinopril in HD patients with hypertension and left ventricular hypertrophy 4

ACE Inhibitors/ARBs (Add-On Therapy)

• May reduce left ventricular mass index based on meta-analysis data 4
• May preserve residual kidney function, especially important in patients with remaining urine output 4
• Critical caveat: Fosinopril did not reduce cardiovascular events and death compared with placebo in HD patients with left ventricular hypertrophy in RCT data, so benefits are primarily on surrogate endpoints 4

Calcium Channel Blockers (Alternative)

• Amlodipine reduced cardiovascular events compared with placebo in HD patients with hypertension 4

Diuretics (Adjunctive Role)

• May help preserve residual diuresis and limit fluid overload in patients with remaining kidney function 4
• Continuation of loop diuretics after HD initiation is associated with lower interdialytic weight gain and lower intradialytic hypotension rates 4
• Should not be considered primary antihypertensive medication in the dialysis setting as they have minimal effect on central hemodynamic indices 4

Monitoring and Reassessment

• Reassess blood pressure response after each intervention using both dialysis unit measurements and out-of-unit monitoring 1
• Continue dry weight challenges until intradialytic blood pressure pattern normalizes or clinical signs of volume depletion appear 1
• Regular assessment of pre- and post-dialysis blood pressure patterns over time rather than isolated readings 6

Critical Pitfalls to Avoid

• Do not prematurely stop dry weight reduction based on persistent intradialytic hypertension—the lag time between volume normalization and BP improvement can extend 8+ months 1
• Do not reduce ultrafiltration rate during the session unless there are clear signs of acute volume depletion 1
• Do not use dialyzable antihypertensive medications that will be removed during dialysis 3, 5
• Do not ignore this pattern—it carries mortality risk comparable to severe intradialytic hypotension 1, 2

Pathophysiologic Understanding

The blood pressure rise during dialysis involves multiple overlapping mechanisms 1:

• Volume overload (primary driver) 1, 2, 3
• Sympathetic nervous system overactivity 1, 2, 3
• Renin-angiotensin-aldosterone system activation 1, 2, 3
• Endothelial dysfunction and arterial stiffness 1, 2

This understanding reinforces why volume control through aggressive dry weight reduction is the cornerstone of management, with medications serving as adjunctive therapy targeting the neurohormonal pathways 1, 2.