Management of Hypertension During Dialysis

Initial Assessment and Approach

The management of hypertension during dialysis should begin by addressing volume overload through adjusting the dialysis prescription, as volume is the most significant contributor to hypertension in dialysis patients 1, 2
Hypertension during dialysis (intradialytic hypertension) is defined as a systolic blood pressure (SBP) rise >10 mm Hg from pre- to post-dialysis, and should prompt a more extensive evaluation of BP and volume management 3
Evaluate for volume overload as the primary cause of hypertension in dialysis patients 1, 2

Gently probe the prescribed target weight to address volume overload, which is the first step in managing hypertension in hemodialysis patients 1, 2
Increase treatment time and/or frequency (possibly through home HD or center-based nocturnal HD) to improve volume control 1, 2, 4
Improve vascular stability during hemodialysis by optimizing ultrafiltration rate 4
Consider using lower dialysate sodium concentration, which may be associated with lower IDWG and BP, though this may increase risk of intradialytic hypotension and cramps 4, 5
Decrease interdialytic weight gain (IDWG) through dietary sodium restriction (2-3 g/day) and patient education 6

If hypertension persists despite optimizing volume status, initiate or adjust antihypertensive medications 3
Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) should be preferred as they cause greater regression of left ventricular hypertrophy and may improve endothelial function 6
Administer antihypertensive drugs preferentially at night to reduce nocturnal BP surge and minimize intradialytic hypotension 6
Consider the dialyzability of medications when selecting antihypertensive agents; non-dialyzable agents may provide more consistent BP control 6

For PD patients with hypertension, maximize peritoneal ultrafiltration and urine output to achieve euvolemia 1, 2
Strategies include shortening dwell time with glucose-based solutions for high transporters, using icodextrin for long dwells, restricting dietary salt, and using diuretics in those with residual kidney function 1, 2
Consider experimental approaches such as low-sodium dialysate or bimodal solutions with glucose and icodextrin 1, 2

La American Society of Nephrology recomienda ajustar el peso seco objetivo mediante pruebas graduales para identificar el verdadero peso seco del paciente, y aumentar el tiempo y/o frecuencia de tratamiento para mejorar el control de volumen 7
La National Kidney Foundation sugiere maximizar la ultrafiltración peritoneal ajustando el tipo de solución, número de intercambios y tiempo de permanencia, y usar icodextrina para permanencias largas para aumentar la ultrafiltración 7

Los bloqueadores de canales de calcio, como el amlodipino, redujeron eventos cardiovasculares comparado con placebo en ensayos controlados aleatorizados en pacientes hipertensos en hemodiálisis, según la American Heart Association 8

La administración de antihipertensivos preferentemente por la noche puede reducir el aumento nocturno de presión arterial y minimizar la hipotensión intradialítica, según la European Renal Association 7

La hipotensión intradialítica puede ser manejada reduciendo la tasa de ultrafiltración en pacientes que exhiben regularmente este patrón, y considerar medicamentos dializables, según la International Society of Nephrology 7

In adult hemodialysis patients, aggressive volume control—by probing the target dry weight downward, extending treatment time or frequency, and limiting dietary sodium to 2–3 g/day—should precede any initiation or escalation of antihypertensive drugs. [9][10]
Volume overload is identified as the predominant driver of hypertension in the hemodialysis population, making its correction the cornerstone of therapy. 9
A systematic reduction of post‑dialysis target weight by 0.2–0.5 kg increments allows clinicians to locate true euvolemia while monitoring for intradialytic hypotension or related symptoms. [9][10]
Increasing dialysis treatment time and/or frequency (including home or nocturnal schedules) enables gentler ultrafiltration rates, reduces cardiovascular stress from rapid fluid removal, and improves blood‑pressure control. [9][10]

Using a lower dialysate sodium concentration (135–138 mEq/L) promotes a net negative sodium balance during treatment, thereby decreasing interdialytic weight gain and aiding blood‑pressure reduction. [9][10]
Maintaining dialysate sodium ≥140 mEq/L is associated with increased thirst, higher interdialytic weight gain, elevated hypertension prevalence, and greater cardiovascular mortality; it should be avoided. [9][10]
Clinicians should be aware that a reduced dialysate sodium level may increase the risk of intradialytic hypotension and muscle cramping; close monitoring and individualized adjustments are required. [9][10]

Antihypertensive medication (e.g., ACE‑inhibitor or ARB) should be started or intensified only after optimal volume status has been achieved, to avoid unnecessary intradialytic hypotension and to target the primary pathophysiology. 9

Patients who experience chronic hypotension on hemodialysis may achieve better tolerance with peritoneal dialysis, although further research is needed to confirm this observation. [9][10]