Hypertension in Dialysis Patients: Clinical Epidemiology, Pathogenesis, Diagnosis, and Treatment

Abstract

In patients with end-stage renal disease (ESRD), hypertension is common, difficult to diagnose, and often poorly controlled. Blood pressure (BP) recordings obtained before or after hemodialysis display a flat or even U-shaped association with cardiovascular events or survival, but this may reflect their poor accuracy, since elevated BP recorded with home or ambulatory BP monitoring is directly associated with shorter survival. Sodium and volume excess is the prominent pathogenic mechanism of hypertension in dialysis patients, but non-volume-mediated pathways, such as activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, structural arterial wall alterations, endothelial dysfunction, sleep apnea, and the use of particular medications like erythropoietin-stimulating agents (ESAs), are also involved in the complex mechanistic background of hypertension in these individuals. Since sodium and volume excess is the most important cause, non-pharmacologic strategies such as dietary sodium restriction, individualized dialysate sodium prescription, and gradual dry-weight reduction should be the initial therapeutic approaches to achieve BP control. If hypertension remains poorly controlled, pharmacologic therapy should be commenced, taking into consideration the particular characteristics of antihypertensive agents. In this chapter, we discuss the epidemiology, pathogenesis, diagnosis, and treatment of hypertension among patients on dialysis in the light of currently available evidence.