Assessment and Management of Hypertension in Patients on Dialysis

Abstract

Hypertension is common, difficult to diagnose, and poorly controlled among patients with ESRD. However, controversy surrounds the diagnosis and treatment of hypertension. Here, we describe the diagnosis, epidemiology, and management of hypertension in dialysis patients, and examine the data sparking debate over appropriate methods for diagnosing and treating hypertension. Furthermore, we consider the issues uniquely related to hypertension in pediatric dialysis patients. Future clinical trials designed to clarify the controversial results discussed here should lead to the implementation of diagnostic and therapeutic techniques that improve long-term cardiovascular outcomes in patients with ESRD. Hypertension is common among patients with ESRD. In this review, we discuss the diagnosis, epidemiology, and management of hypertension among dialysis patients. We also review areas of existing controversies and briefly discuss the issue of hypertension in pediatric dialysis patients. EPIDEMIOLOGYThe prevalence, treatment, and control of hypertension among people on hemodialysis (HD) have used varying definitions to diagnose hypertension. The epidemiology differs based on how BP is measured: either before and after dialysis or using ambulatory BP recordings. Epidemiology with Routine BP MeasurementsThe prevalence of hypertension (defined as 1-week average predialysis systolic BP [SBP] measurements .150 mmHg or diastolic BP [DBP].85 mmHg or the use of antihypertensive medications) was 86% among 2535 clinically stable adult HD patients participating in a multicenter trial. 1 Among hypertensive patients, 12% did not receive antihypertensive drugs, 58% were treated but not controlled, and only 30% were controlled. The use of antihypertensive drugs has been reported to vary from 59% to 83%. [2][3][4][5] Furthermore, even among children on long-term HD, similar findings have been reported. 6 Several studies have confirmed greater antihypertensive drug use to be associated with poorer control. 7,8 It should be noted that antihypertensive drug use per se do not lead to worse BP control; in the absence of adequate volume control, increasing antihypertensive drug use may simply reflect difficult-to-control BP. Epidemiology Using Ambulatory BP MeasurementsThe prevalence of hypertension (defined by either a 44-hour interdialytic ambulatory BP of $135/85 mmHg or the prescription of any antihypertensive agent) was 86% among 369 chronic HD patients. 8 Although hypertension was being treated with antihypertensive drugs in 89% of patients, it was adequately controlled only in 38%. The independent determinants of poor control were the use of antihypertensive drugs and an expanded extracellular volume state. If patients were volume overloaded, nearly 80% became hypertensive when medications were Published online ahead of print. Publication date available at www.jasn.org.

Effect of Lisinopril and Atenolol on Aortic Stiffness in Patients on Hemodialysis

“…Indeed, changes in BP over 6 months were, if anything, numerically higher in the atenolol group relative to the lisinopril group. Of note, we confirmed BP control with ABPM during the interdialytic period, which is considered the most reliable method of BP assessment in hemodialysis (12,13). Although ambulatory BP between groups was no different, superiority of atenolol over lisinopril in improving BP control is supported by the fact that patients treated with lisinopril in the HDPAL Trial required more aggressive volume management and higher numbers of antihypertensive drugs.…”

“…Strengths of this randomized, controlled study were the echocardiographic determination of PWV in the elastic part of the descending aorta in contrast to the tonometric method for estimating carotid-to-femoral PWV that also includes muscular-type arterial segments. Another notable advantage was the use of the most reliable technique of ABPM (12,13) to assess efficacy of randomized drugs in improving BP control. However, this study also had some limitations.…”

Ambulatory Recording of Wave Reflections and Arterial Stiffness during Intra- and Interdialytic Periods in Patients Treated with Dialysis

“…Estimation of arterial stiffness indexes in these studies relied on peridialytic BP, which exhibits high variability, poor reproducibility, and provides inaccurate estimation of interdialytic ambulatory BP (12,14), the most valid method for BP assessment in hemodialysis (16). The present study overcomes this limitation, showing a gradual interdialytic increase in wave reflections and a steady pattern of PWV during the whole 48-hour recording.…”

“…Recent data suggest that ambulatory BP in hemodialysis patients shows independent associations with cardiovascular mortality, whereas office BP does not (15). Most experts agree that ABPM (preferably performed during 48 hours) should be widely used in hemodialysis to accurately assess BP control and perform risk stratification (16).…”

A preliminary study on the development of electronic pump system using Arduino controller

“…The researchers opine that a study of several ways in controlling the flow of liquid pressure is sufficient at this stage. Besides, a development of controlling the flow of liquid pressure is important tasks to be decided [9].…”