Resistant hypertension in dialysis

Abstract

Hypertension is the most common finding in chronic kidney disease patients, with prevalence ranging from 60% to 90% depending on the stage and etiology of the disease. It is also a significant independent risk factor for cardiovascular disease, progression to end-stage kidney disease, and mortality. According to the current guidelines, resistant hypertension is defined in the general population as uncontrolled blood pressure on 3 or more antihypertensive drugs in adequate doses or when patients are on 4 or more antihypertensive drug categories irrespective of the blood pressure control, providing that antihypertensive treatment included diuretics. The currently established definitions of resistant hypertension are not directly applicable to the end-stage renal disease setting. The diagnosis of true resistant hypertension requires confirmation of adherence to therapy and confirmation of uncontrolled blood pressure values by ambulatory blood pressure measurement or home blood pressure measurement. In addition, the term of apparent treatment-resistant hypertension defined as an uncontrolled blood pressure on three or more antihypertensive medication classes, or use of four or more medications regardless of blood pressure level was introduced. In this comprehensive review we focused on the definitions of hypertension, therapeutic targets in patients on renal replacement therapy, including the limitations and biases. We discussed the issue of pathophysiology and assessment of blood pressure in dialyzed population, management of resistant hypertension as well as available data on prevalence of apparent treatment-resistant hypertension in end-stage renal disease. Concluding, larger sample-size and even higher quality studies about drug adherence should be conducted in the population of patients with the end-stage renal disease who are on dialysis. It also should be determined how and when blood pressure should be measured in the group of dialysis patients. Additionally, it should be stated what the target blood pressure values in this group of patients really are. The definition of resistant hypertension in this group should be revisited, and its relationship to both subclinical and clinical endpoints should be established.

Apparently Resistant Hypertension in Polish Hemodialyzed Population: Prevalence and Risk Factors

“…In our recent review [ 17 ], we discussed that the currently established definitions of resistant hypertension are not directly applicable to the end-stage renal disease setting. Additionally, we stressed that the target blood pressure values in this group of patients should be established.…”

“…The definition of resistant hypertension in this group should be revisited, and its relationship to both subclinical and clinical endpoints should be established. We also underly that the studies assessing the incidence of aTRH in patients with ESKD on renal replacement therapy are scarce [ 17 ] and performed in various populations on different continents [ 11 , 16 , 18 , 19 ]. Moreover, these studies were performed in selected, usually tertiary centers; hence, their populations may not reflect real-world data.…”