Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH)*

Abstract

In patients with end-stage renal disease (ESRD) treated with haemodialysis or peritoneal dialysis, hypertension is common and often poorly controlled. Blood pressure (BP) recordings obtained before or after haemodialysis display a J- or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar haemodynamic setting related to dialysis treatment. Elevated BP detected by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnoea and the use of erythropoietin-stimulating agents may also be involved. Non-pharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium and volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.

Pathogenesis and treatment of hypertension in haemodialysis patients with chronic kidney disease

“…ABPM extended to 44-hour in comparison to 24-hour covers the whole mid-week dialysis interval [18]. This method is also www.ah.viamedica.pl helpful in identifying patients without physiological nocturnal decrease of blood pressure (dipping pattern) and has a prognostic value in assessing the risk of left ventricular hypertrophy [42].…”

“…The measurements should be taken twice a day on days without haemodialysis. Every time the blood pressure measurements should be performed in a quiet room, with the patient in seated position, back and arm supported, after 5 minutes of rest and with two measurements per occasion taken 1-2 minutes apart [18]. Then, the arithmetic average of measurements from several days should be calculated [48,49].…”

“…Thresholds and methods are defined by the ASH/ASN (American Society of Hypertension/ /American Society of Nephrology) [53], the EURE-CA-m (European Renal and Cardiovascular Medicine) working group of ERA-EDTA (The European Renal Association -European Dialysis and Transplant Association) [54] and the relevant ESH (European Society of Hypertension) Guidelines [55][56][57]. According to these recommendations hypertension in haemodialysis patients should be diagnosed on the basis of HBPM if an average BP ≥ 135/85 mmHg for measurements done in the morning and in the evening over 6 non-dialysis days (covering a period www.ah.viamedica.pl of 2 weeks) is observed [48,49,18]. Hypertension in HD patients should be also defined on the basis of ABPM if an average BP ≥ 130/80 mmHg over 44-hour monitoring, covering the whole mid-week dialysis interval, is observed [42,18].…”

“…According to these recommendations hypertension in haemodialysis patients should be diagnosed on the basis of HBPM if an average BP ≥ 135/85 mmHg for measurements done in the morning and in the evening over 6 non-dialysis days (covering a period www.ah.viamedica.pl of 2 weeks) is observed [48,49,18]. Hypertension in HD patients should be also defined on the basis of ABPM if an average BP ≥ 130/80 mmHg over 44-hour monitoring, covering the whole mid-week dialysis interval, is observed [42,18]. For haemodialysis patients no recommendations can be made on the basis of pre-or post-dialysis BP [18].…”

“…In contrast to the guidelines for the general population, in which systolic blood pressure of ≤ 140 mmHg is considered the treatment target, a debate remains regarding the target blood pressure in haemodialysis patients [17]. Hypertension in haemodialysis patients is an unique diagnostic, prognostic and therapeutic challenge [18]. The main aim of this review is to systematize the current state of knowledge concerning hypertension in haemodialysis patients, especially pathophysiology, variability, measurement methods, target-values of blood pressure, and mode of antihypertensive treatment.…”