Abstract
Hypertension (blood pressure > 140/90 mm Hg) is very common in patients undergoing regular dialysis, with a prevalence of 70-80%, and only the minority has adequate blood pressure (BP) control. In contrast to the unclear association of predialytic BP recordings with cardiovascular mortality, prospective studies showed that interdialytic BP, recorded as home BP or by ambulatory blood pressure monitoring in hemodialysis patients, associates more closely with mortality and cardiovascular events. Although BP is measured frequently in the dialysis treatment environment, aspects related to the measurement technique traditionally employed may be unsatisfactory. Several other tools are now available and being used in clinical trials and in clinical practice to evaluate and treat elevated BP in chronic kidney disease (CKD) patients. While we wait for the ongoing review of the CKD Blood Pressure KIDGO guidelines, there is no guideline for the dialysis population addressing this important issue. Thus, the objective of this review is to provide a critical analysis of the information available on the epidemiology, pathogenic mechanisms, and the main pillars involved in the management of blood pressure in stage 5-D CKD, based on current knowledge.
Highlights
Understanding the mechanisms, evaluating, and defining the best management of blood pressure (BP) in patients receiving renal replacement therapies through hemodialysis (HD) or peritoneal dialysis (PD), is a significant challenge for healthcare professionals
The objective of this review is to provide a critical analysis of the information available on the epidemiology, pathogenic mechanisms, and the main pillars involved in the management of blood pressure in stage 5-D chronic kidney disease (CKD), based on current knowledge
renin-angiotensin-aldosterone system (RAAS) inhibitors should be used in CKD-VD patients because these agents are beneficial for cardiac disease frequently observed in dialysis patients and are effective in reducing left ventricular mass and mortality.[115,116]. Related to this topic of interest, there is an ongoing phase 3 trial evaluating Spironolactone 25 mg (Aldosterone bloCkade for Health Improvement EValuation in End-stage Renal Disease (ACHIEVE) - https://clinicaltrials.gov/ct2/ show/NCT03020303) and its purpose is to determine if spironolactone reduces death or hospitalization for heart failure and if the drug is well tolerated in patients that require dialysis
Summary
Understanding the mechanisms, evaluating, and defining the best management of blood pressure (BP) in patients receiving renal replacement therapies through hemodialysis (HD) or peritoneal dialysis (PD), is a significant challenge for healthcare professionals. The scenario for peritoneal dialysis (PD) patients is not different, and the variability reported for the prevalence of hypertension is even higher ranging from approximately 30 to more than 90%.10 This variability is mostly related to differences in the definitions used to diagnose hypertension and the tools applied in various studies.[5] Epidemiological studies in hemodialysis patients in USA, using different ways to define hypertension, revealed that 72 to 88% of all patients studied had elevated BP.[4,11,12] in those studies, a high proportion of patients with elevated blood pressure was taking antihypertensive agents and the number of patients with controlled BP was low, between 30-50%.4,11. These data suggest that long-term hypertension is frequently, not well controlled, and a significant risk factor for cardiovascular events in CKD hemodialysis patients
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