How should hypertension be managed in a chronic kidney disease patient undergoing dialysis?

Management of Hypertension in CKD Patients During Dialysis

Volume control through achieving euvolemia should be the first-line approach to managing hypertension in dialysis patients, as volume overload underlies most cases of BP elevation in this population. 1

Initial Assessment and BP Measurement

• Do not rely on pre- and post-dialysis BP measurements alone for diagnosis and management—these are inadequate for assessing true BP control 2
• Use home BP monitoring or ambulatory BP monitoring (ABPM) as the gold standard for diagnosing hypertension in dialysis patients 2
• Monitor for intradialytic hypertension: SBP increase >10 mm Hg from pre- to post-dialysis in at least 4 of 6 consecutive treatments warrants extensive evaluation of BP and volume management 1
• Assess for intradialytic hypotension: any symptomatic BP decrease or nadir intradialytic SBP <90 mm Hg requires reassessment of volume status and medication regimen 1

BP Targets

An individualized approach is necessary, with particular focus on avoiding overly low BPs, as numerous observational studies have suggested harm from lower BPs in dialysis patients 1

• Consider extrapolating from general population guidelines (ACC/AHA target 130/80 mm Hg or ESH/ESC target <130 mm Hg for age <65 years, 130-140 mm Hg for others), but recognize these don't account for the unique cardiovascular risk profile in dialysis 1
• Avoid targeting excessively low BP thresholds as this may heighten cardiovascular risk 1, 2

First-Line Management: Volume Control (Non-Pharmacologic)

Volume overload underlies most cases of BP elevation in dialysis, so nonpharmacologic treatments should be considered first 1

Sodium and Fluid Management

• Restrict dietary sodium intake 3
• Eliminate intradialytic sodium gain via individualized dialysate sodium prescription 3
• Critically reassess and optimize dry weight through out-of-unit BP measurements 1
• Minimize interdialytic weight gain (IDWG) 1

Dialysis Prescription Optimization

• Provide adequate dialysis time of at least 4 hours to deliver adequate dialysis dose and facilitate achievement of dry weight 4
• Lower ultrafiltration (UF) rates by increasing HD time and/or decreasing IDWG, as higher UF rates (even as low as 6 ml/h per kg) are associated with higher mortality risk 1
• Consider lengthening or adding dialysis treatments to reduce UF rates 1

Pharmacologic Management

Initiate or up-titrate antihypertensive medications only if BP remains above target after nonpharmacologic measures directed at volume control 1

First-Line Medication Choice

β-blockers should be considered as first-line pharmacotherapy in dialysis patients, as emerging clinical trial evidence suggests they are more effective than RAS blockers in reducing BP and protecting from serious adverse cardiovascular complications 2, 3

• β-blockers can reduce sympathetic overactivity and left ventricular hypertrophy, which contribute to high incidence of arrhythmias and sudden cardiac death 2
• Consider drug dialyzability: nondialyzable β-blockers (e.g., propranolol) may be associated with lower mortality risk due to preserved intradialytic protection against arrhythmias 1
• Avoid nondialyzable medications in the setting of frequent intradialytic hypotension (e.g., carvedilol showed higher mortality rates versus dialyzable metoprolol, attributed to higher likelihood of intradialytic hypotension) 1

Second-Line Options

Long-acting calcium channel blockers and RAS blockers (ACE inhibitors/ARBs) are reasonable second-line choices 1, 3

• These agents considered first-line in the general population can also be used to lower BP in dialysis patients 1
• Choose medications based on patient characteristics, cardiovascular indications, and availability 1

Additional Considerations

• For relatively stable intradialytic BP, use longer-acting, once-daily medications to improve adherence and reduce pill burden 1
• Individualize timing of antihypertensive medication administration, taking into account interdialytic BP and frequency of intradialytic hypotension 1
• Mineralocorticoid receptor antagonists have shown promising results in reducing mortality, but safety issues such as hyperkalemia or hypotension require further evaluation 2

Management of Resistant Hypertension

In patients with inadequately controlled BP despite adherence to maximally tolerated doses of a β-blocker, long-acting dihydropyridine calcium channel blocker, and RAS inhibitor, volume-mediated hypertension is the most important treatable cause 4

• Do not simply increase the number of BP-lowering medications—this strategy will likely fail if volume overload is not adequately recognized or treated 4
• Instead, implement sodium-restricted diet and dialysate to facilitate achievement of dry weight 4

Critical Pitfalls to Avoid

• Do not reduce medications to allow for enhanced UF if BP is well controlled and antihypertensive medications interfere with UF—this is only reasonable in specific circumstances 1
• Avoidance of intradialytic hypotension should not come at the expense of maintaining euvolemia or ensuring adequate dialysis time 1
• Do not use pre- and post-dialysis BP measurements as the sole basis for diagnosis and treatment decisions 2
• Be aware that the effectiveness of withholding antihypertensive agents before dialysis in reducing intradialytic hypotension remains unknown 1