Blood Pressure Management in Elderly Dialysis Patients

Understanding BP Targets

The National Kidney Foundation's K/DOQI guidelines recommend a predialysis blood pressure target of <140/90 mmHg and a postdialysis target of <130/80 mmHg for hemodialysis patients 1, 2, 3
The American Journal of Kidney Diseases suggests measuring blood pressure with the patient in a sitting position 4

Elderly patients are at increased risk for orthostatic hypotension and intradialytic hypotension, and should be treated with caution if standing systolic BP is <110 mmHg 5
A stepped-care approach is preferred over starting with 2-drug therapy in elderly patients, with close monitoring for adverse effects such as acute kidney injury, electrolyte abnormalities, and hypotension 5, 6

The recommended blood pressure targets for dialysis patients are based largely on expert opinion rather than strong evidence, with most observational data showing a "U" or "J"-shaped relationship between blood pressure and mortality 1, 6
The American College of Cardiology and American Heart Association do not recommend specific blood pressure goals for dialysis patients due to lack of evidence 6

There is poor correlation between dialysis clinic blood pressure measurements and mean interdialytic blood pressure assessed using 44-hour ambulatory blood pressure monitoring, and home blood pressure recordings may provide more accurate measurements 6, 7
Blood pressure should be measured in the thighs or legs using appropriate cuff size and in the supine position in patients who have undergone multiple vascular access procedures in both arms 4

Management of hypertension in dialysis patients requires attention to both fluid status and antihypertensive medications, with strategies including low sodium intake, increased ultrafiltration, longer dialysis sessions, and more frequent dialysis 4
If volume control is insufficient, antihypertensive drugs should be initiated, with ACE inhibitors or ARBs often recommended as first-line agents due to their benefits in reducing left ventricular hypertrophy 1, 2, 8
Beta-blockers are preferred in patients with coronary artery disease, and calcium channel blockers and alpha-blockers may be needed for adequate control 8, 9

Antihypertensive drugs should be administered at night to reduce nocturnal blood pressure surge and minimize intradialytic hypotension, and the dialyzability of medications should be considered when selecting therapy 4
Erythropoietin therapy can worsen hypertension, particularly in patients with pre-existing hypertension 2, 3