Management of Hypertension in Hemodialysis Patients

Initial Assessment and Management

Evaluate volume status as excessive intravascular volume is a major pathogenic factor of hypertension in dialysis patients, and assess for symptoms of end-organ damage, according to the American Journal of Kidney Diseases guidelines 1, 2
Measure blood pressure according to guidelines: patient seated quietly for at least 5 minutes, feet on floor, arm supported at heart level, as recommended by the American Journal of Kidney Diseases 1
Consider that pre-dialysis blood pressure may overestimate true blood pressure by approximately 14/7 mmHg, as noted by the American Journal of Kidney Diseases 1

For hemodialysis patients, a reasonable goal is predialysis blood pressure of ≤140/90 mmHg measured in the sitting position, as suggested by the American Journal of Kidney Diseases 2, 3
This target minimizes the occurrence of left ventricular hypertrophy and death in dialysis patients, according to the American Journal of Kidney Diseases 2, 3
Avoid excessive blood pressure reduction as a U-shaped relationship exists between blood pressure and mortality in dialysis patients, with increased risk at both very low and very high levels, as reported by the American Journal of Kidney Diseases and Kidney International 4, 5

Focus on achieving dry weight through ultrafiltration during the dialysis session, and consider extending dialysis time or increasing ultrafiltration rate if clinically appropriate, as recommended by the American Journal of Kidney Diseases 2, 6
Emphasize dietary sodium restriction (2 g/day sodium intake), and monitor for orthostatic hypotension and intradialytic hypotension during treatment, according to the American Journal of Kidney Diseases 2, 7
ACE inhibitors or ARBs are preferred as first-line medications for pharmacological management, as they reduce left ventricular hypertrophy and are associated with decreased mortality in dialysis patients, as noted by the American Journal of Kidney Diseases 2, 3

Consider dialyzability of antihypertensive medications when selecting agents, as recommended by the American Journal of Kidney Diseases 7
Home blood pressure monitoring or ambulatory blood pressure monitoring provides more accurate assessment of true blood pressure than in-center measurements, according to the American Journal of Kidney Diseases and Kidney International 4, 5
Evaluate for secondary causes of resistant hypertension if blood pressure remains uncontrolled despite optimal therapy, as suggested by the American Journal of Kidney Diseases 2

Proceed with catheter change after initiating appropriate blood pressure management, and monitor closely for hemodynamic changes during the procedure, as recommended by the American Heart Association, as published in Circulation 8
Continue antihypertensive medications perioperatively unless contraindicated, according to the American Heart Association, as published in Circulation 8