Hypertension in Patients Treated With In-Center Maintenance Hemodialysis: Current Evidence and Future Opportunities: A Scientific Statement From the American Heart Association

Abstract

Nearly 500 000 individuals are treated with maintenance hemodialysis for kidney failure in the United States, and roughly half will die of cardiovascular causes. Hypertension, an important and modifiable risk factor for cardiovascular disease, is observed in >80% of patients treated with maintenance hemodialysis. The pathophysiology of hypertension in patients treated with maintenance hemodialysis is multifactorial and differs from that seen in other patient populations. Factors that contribute to hypertension in patients treated with hemodialysis include volume overload, arterial stiffness, enhanced activity of the sympathetic nervous and renin-angiotensin-aldosterone systems, endothelial dysfunction, and use of erythropoietin-stimulating agents. This scientific statement reviews the current evidence on defining, diagnosing, and treating hypertension in patients treated with maintenance hemodialysis and highlights opportunities for future investigation, including studies on blood pressure targets and treatment strategies.

Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association

“…133–135 When medication classes such as β-adrenergic receptor blockers or ACE inhibitors are used, the dialyzability of these agents and their timing with the dialysis cycle should be factored into the treatment plan. 136 Ongoing trials are looking at potential cardiovascular benefits with the use of steroidal mineralocorticoid receptor antagonists (NCT01848639, NCT03020303) and SGLT2 inhibitors (NCT05685394, NCT05179668, NCT05374291) in patients on dialysis. There is a limited role for routine initiation of statins in patients on dialysis without known ASCVD, but continuation of these agents when initiated before dialysis initiation is reasonable.…”

A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association

“…188,189 In patients on hemodialysis, factoring in the dialyzability of GDMT therapies such as ACE inhibitors, β-blockers, and other antihypertensives is essential for optimal medical management. 190 For patients on dialysis, statin initiation does not reduce the risk of future ASCVD events. 191,192 However, in a post hoc analysis of patients with diabetes on dialysis, rosuvastatin use was associated with lower risk of adverse cardiovascular outcomes.…”

Interdialytic home systolic blood pressure variability increases all‐cause mortality in hemodialysis patients

“…6 Nevertheless, the effect of blood pressure on the prognosis of patients with MHD is more complicated, as blood pressure can influence patient prognosis, irrespective of predia-lysis， interdialytic，or after dialysis, abnormal blood pressure levels, whether excessively high or low, are significantly correlated with an increased risk of cardiovascular and cerebrovascular adverse events, as well as all-cause mortality. 7 Despite well-controlled mean blood pressure, high variability, and paroxysmal hypertension during visits still significantly increase the risk of cardiovascular adverse events, this illustrated that the prognosis of patients with MHD is not only dependent on the level of blood pressure but also correlated with BPV. 8 Recently, BPV has been acknowledged as an independent cardiovascular risk factor in the general population and in patients with hypertension.…”