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J Am Soc Nephrol 17: 8-10, 2006
© 2006 American Society of Nephrology

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Hemodialysis Clinical Practice Guidelines for the Canadian Society of Nephrology

CHAPTER 2: Management of Blood Pressure in Hemodialysis Patients

Kailash Jindal, Workgroup Chair, Christopher T. Chan, Clement Deziel, David Hirsch, Steven D. Soroka, Marcello Tonelli and Bruce F. Culleton, CPG Chair


   I. Blood Pressure Measurement—Timing and Targets
Top
 I. Blood Pressure Measurement-...
II. Management of Hypertension
 References
 
Recommendations

  1. Use predialysis blood pressure to guide therapy. (Grade C)
  2. Target predialysis blood pressure to be <140/90 (Grade C); optimal blood pressure is unknown.
  3. Ambulatory recording devices or home self-measurement should be applied to patients where difficulty occurs in reaching target blood pressure levels. (Grade D, opinion)

Background
Blood pressure (BP) varies significantly in hemodialysis patients depending upon the time taken: predialysis, postdialysis, or interdialytic. It is currently unknown which time period correlates best with long-term patient outcome, given the lack of treatment trials (1–3). It is difficult to relate usual clinical BP measurements in hemodialysis patients to published research studies because usual systolic and diastolic pressures both pre- and postdialysis are significantly higher by about 14/5 mmHg than if measured according to standardized American Heart Association criteria (4).

There is convincing evidence in the general population that hypertension is associated with increased cardiovascular mortality and morbidity, and that its control can reduce these adverse consequences (5). Observational studies in the hemodialysis population have demonstrated that hypertension is also associated with adverse consequences in these patients, especially with longer-term follow-up (6–9). Although there are no controlled trials demonstrating that control of BP by dialytic or pharmacologic means in hemodialysis patients reduces these mortality and morbidity rates, it would seem reasonable to generalize from the extensive evidence available for the general population with hypertension (2,3).

Long-term observational studies suggest that even mean arterial BP of >98 mmHg is associated with an increased risk of death compared with lower pressures (8). Other observational studies, performed in populations with older patients having a higher prevalence of cardiovascular comorbidity than the study cited above, suggest that low pre- and/or postdialysis BP may be associated with a higher risk of death than BP in excess of 140 to 150 mmHg systolic (10,11). The discrepancy between the above observations may well be an artifact of the confounding of reduced BP by severe cardiac disease (12).

Given the absence of enough data to define an optimal BP in the dialysis population, the committee selected a target predialysis BP of <140/90 mmHg. The lower target of <130/80 mmHg recommended by the Canadian Hypertension Education Program (13) for patients with diabetes or chronic kidney disease was not selected, because there are two randomized clinical trials documenting no benefit for a lower target in nondialysis patients (14,15) and associative studies (above) suggesting possible risks for the lower target in dialysis patients.


   II. Management of Hypertension
Top
 I. Blood Pressure Measurement-...
 II. Management of Hypertension
References
 
Recommendations

  1. Limit patients to a dietary sodium intake of 80 to 100 mEq/d. (Grade C)
  2. Reduce patient weight gradually by ultrafiltration, targeting for the "dry" weight, as antihypertensive medications are withdrawn. (Grade C)
  3. "Paradoxical" rises in BP during individual dialysis/ultrafiltration sessions should be corrected by further gradual volume removal. (Grade D)

Background
In nondialysis hypertensive patients, dietary sodium restriction may lower BP by 4.2/2.0 mmHg to 5.2/3.7 mmHg (16). It is also possible to control hypertension in many hemodialysis patients by restriction of dietary sodium to <100 mEq/d and aggressive and recurrent efforts to reduce body weight by ultrafiltration during dialysis to the "dry" weight. "Dry" weight may be defined as the lowest attainable weight at which patients are normotensive without antihypertensive medications and do not have symptoms of postural hypotension or intra/postdialytic hypotension. During this process of probing for "dry" weight, antihypertensive medications are gradually withdrawn (8,17). In turn, improved survival is associated with better BP control (8,18). Paradoxical elevation of BP during ultrafiltration is associated with volume overload and can be corrected by further aggressive reduction in target body weight (19).

The lag phenomenon has been described in hemodialysis patients whereby BP reduction lags behind reduction in volume status for weeks to months (20). Thus, efforts to control BP by reduction of dry weight must be gradual but persistent.

There is preliminary, nonrandomized evidence that extended forms of hemodialysis such as nocturnal dialysis and short daily dialysis are effective in improving BP control (21). In contrast, there is no convincing evidence at this time that intradialytic volume monitoring is effective in reducing symptoms or improving BP control. In fact, a recent randomized trial suggests that intradialytic volume monitoring may be harmful (22).

  1. Avoid positive sodium balance induced by hypertonic dialysate and/or sodium profiling during volume status adjustment. (Grade C)
  2. Reduce dialysate temperature when intradialytic hypotension limits ultrafiltration. (Grade C)
  3. If antihypertensive agents are required, select agents with pharmacokinetics suitable for dialysis patients and appropriate for existing comorbid conditions. (Grade D)

Background
Hypertonic dialysate and sodium profiling may induce net positive sodium balance in some patients, worsening hypertension and interdialytic thirst (23–25).

Lowering dialysate temperature is often effective in moderating intradialytic hypotension during attempts to achieve dry weight, particularly for hypothermic patients. A minimum dialysate temperature of 35°C has been used if feedback-controlled isothermic dialysis is not available (26,27).

There are no published controlled trials of specific antihypertensive agents in dialysis patients, and retrospective studies have provided conflicting evidence for the possible survival benefits of various classes of antihypertensive drugs (28–30). Long-acting (renally-excreted) agents such as atenolol, perindopril, or lisinopril can control hypertension occurring in dialysis patients. Administered thrice weekly after dialysis, these agents can assist in BP control without inducing significant hypotension (31,32).

Recommendations for Research

  1. Treatment trials are required in which specific BP targets in hemodialysis patients are compared with regard to mortality and morbidity outcomes.
  2. Randomized trials are needed to determine the optimal use of specific classes of antihypertensive agents in hemodialysis patients.


   References
Top
 I. Blood Pressure Measurement-...
 II. Management of Hypertension
 References
 

  1. Santos SF, Mendes RB, Santos CA, Dorigo D, Peixoto AJ: Profile of interdialytic blood pressure in hemodialysis patients. Am J Nephrol 23 : 96 –105, 2003[CrossRef][Medline]
  2. Mailloux LU, Haley WE: Hypertension in the ESRD patient: Pathophysiology, therapy, outcomes, and future directions. Am J Kidney Dis 32 : 705 –719, 1998[Medline]
  3. Levey AS, Beto JA, Coronado BE, Eknoyan G, Foley RN, Kasiske BL, Klag MJ, Mailloux LU, Manske CL, Meyer KB, Parfrey PS, Pfeffer MA, Wenger NK, Wilson PW, Wright JT Jr: Controlling the epidemic of cardiovascular disease in chronic renal disease: What do we know? What do we need to learn? Where do we go from here? National Kidney Foundation Task Force on Cardiovascular Disease. Am J Kidney Dis 32 : 853 –906, 1998[Medline]
  4. Rahman M, Griffin V, Kumar A, Manzoor F, Wright JT Jr, Smith MC: A comparison of standardized versus "usual" blood pressure measurements in hemodialysis patients. Am J Kidney Dis 39 : 1226 –1230, 2002[CrossRef][Medline]
  5. Sytkowski PA, D’Agostino RB, Belanger AJ, Kannel WB: Secular trends in long-term sustained hypertension, long-term treatment, and cardiovascular mortality. The Framingham Heart Study, 1950 to 1990. Circulation 93 : 697 –703, 1996[Abstract/Free Full Text]
  6. Horl MP, Horl WH: Hemodialysis-associated hypertension: Pathophysiology and therapy. Am J Kidney Dis 39 : 227 –244, 2002[CrossRef][Medline]
  7. Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE: Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Kidney Int 49 : 1379 –1385, 1996[Medline]
  8. Charra B, Calemard E, Ruffet M, Chazot C, Terrat JC, Vanel T, Laurent G: Survival as an index of adequacy of dialysis. Kidney Int 41 : 1286 –1291, 1992[Medline]
  9. Agarwal R: Hypertension and survival in chronic hemodialysis patients—Past lessons and future opportunities. Kidney Int 67 : 1 –13, 2005[CrossRef][Medline]
  10. Zager PG, Nikolic J, Brown RH, Campbell MA, Hunt WC, Peterson D, Van SJ, Levey A, Meyer KB, Klag MJ, Johnson HK, Clark E, Sadler JH, Teredesai P: "U" curve association of blood pressure and mortality in hemodialysis patients. Medical Directors of Dialysis Clinic, Inc. Kidney Int 54 : 561 –569, 1998[CrossRef][Medline]
  11. Port FK, Hulbert-Shearon TE, Wolfe RA, Bloembergen WE, Golper TA, Agodoa LY, Young EW: Predialysis blood pressure and mortality risk in a national sample of maintenance hemodialysis patients. Am J Kidney Dis 33 : 507 –517, 1999[Medline]
  12. Kalantar-Zadeh K, Block G, Humphreys MH, Kopple JD: Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients. Kidney Int 63 : 793 –808, 2003[CrossRef][Medline]
  13. Khan NA, McAlister FA, Lewanczuk RZ, Touyz RM, Padwal R, Rabkin SW, Leiter LA, Lebel M, Herbert C, Schiffrin EL, Herman RJ, Hamet P, Fodor G, Carruthers G, Culleton B, Dechamplain J, Pylypchuk G, Logan AG, Gledhill N, Petrella R, Campbell NR, Arnold M, Moe G, Hill MD, Jones C, Larochelle P, Ogilvie RI, Tobe S, Houlden R, Burgess E, Feldman RD: The 2005 Canadian Hypertension Education Program recommendations for the management of hypertension: Part II—Therapy. Can J Cardiol 21 : 657 –672, 2005[Medline]
  14. Wright JT Jr, Bakris G, Greene T, Agodoa LY, Appel LJ, Charleston J, Cheek D, Douglas-Baltimore JG, Gassman J, Glassock R, Hebert L, Jamerson K, Lewis J, Phillips RA, Toto RD, Middleton JP, Rostand SG: Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: Results from the AASK trial. JAMA 288 : 2421 –2431, 2002[Abstract/Free Full Text]
  15. Ruggenenti P, Perna A, Loriga G, Ganeva M, Ene-Iordache B, Turturro M, Lesti M, Perticucci E, Chakarski IN, Leonardis D, Garini G, Sessa A, Basile C, Alpa M, Scanziani R, Sorba G, Zoccali C, Remuzzi G: Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): Multicentre, randomised controlled trial. Lancet 365 : 939 –946, 2005[CrossRef][Medline]
  16. He FJ, MacGregor GA: Effect of modest salt reduction on blood pressure: A meta-analysis of randomized trials. Implications for public health. J Hum Hypertens 16 : 761 –770, 2002[CrossRef][Medline]
  17. Ozkahya M, Toz H, Unsal A, Ozerkan F, Asci G, Gurgun C, Akcicek F, Mees EJ: Treatment of hypertension in dialysis patients by ultrafiltration: Role of cardiac dilatation and time factor. Am J Kidney Dis 34 : 218 –221, 1999[Medline]
  18. Charra B, Chazot C, Jean G, Hurot JM, Vanel T, Terrat JC, VoVan C: Long 3 x 8 hr dialysis: A three-decade summary. J Nephrol 16[Suppl 7] : S64 –S69, 2003
  19. Cirit M, Akcicek F, Terzioglu E, Soydas C, Ok E, Ozbasli CF, Basci A, Mees EJ: 'Paradoxical’ rise in blood pressure during ultrafiltration in dialysis patients. Nephrol Dial Transplant 10 : 1417 –1420, 1995[Abstract/Free Full Text]
  20. Charra B, Bergstrom J, Scribner BH: Blood pressure control in dialysis patients: Importance of the lag phenomenon. Am J Kidney Dis 32 : 720 –724, 1998[Medline]
  21. Walsh M, Culleton B, Tonelli M, Manns B: A systematic review of the effect of nocturnal hemodialysis on blood pressure, left ventricular hypertrophy, anemia, mineral metabolism, and health-related quality of life. Kidney Int 67 : 1500 –1508, 2005[CrossRef][Medline]
  22. Reddan DN, Szczech LA, Hasselblad V, Lowrie EG, Lindsay RM, Himmelfarb J, Toto RD, Stivelman J, Winchester JF, Zillman LA, Califf RM, Owen WF Jr: Intradialytic blood volume monitoring in ambulatory hemodialysis patients: A randomized trial. J Am Soc Nephrol 16 : 2162 –2169, 2005[Abstract/Free Full Text]
  23. Sang GL, Kovithavongs C, Ulan R, Kjellstrand CM: Sodium ramping in hemodialysis: A study of beneficial and adverse effects. Am J Kidney Dis 29 : 669 –677, 1997[Medline]
  24. de Paula FM, Peixoto AJ, Pinto LV, Dorigo D, Patricio PJ, Santos SF: Clinical consequences of an individualized dialysate sodium prescription in hemodialysis patients. Kidney Int 66 : 1232 –1238, 2004[CrossRef][Medline]
  25. Song JH, Park GH, Lee SY, Lee SW, Lee SW, Kim MJ: Effect of sodium balance and the combination of ultrafiltration profile during sodium profiling hemodialysis on the maintenance of the quality of dialysis and sodium and fluid balances. J Am Soc Nephrol 16 : 237 –246, 2005[Abstract/Free Full Text]
  26. Maggiore Q, Pizzarelli F, Santoro A, Panzetta G, Bonforte G, Hannedouche T, Varez de Lara MA, Tsouras I, Loureiro A, Ponce P, Sulkova S, Van RG, Brink H, Kwan JT: The effects of control of thermal balance on vascular stability in hemodialysis patients: Results of the European randomized clinical trial. Am J Kidney Dis 40 : 280 –290, 2002[CrossRef][Medline]
  27. Fine A, Penner B: The protective effect of cool dialysate is dependent on patients’ predialysis temperature. Am J Kidney Dis 28 : 262 –265, 1996[Medline]
  28. Efrati S, Zaidenstein R, Dishy V, Beberashvili I, Sharist M, Averbukh Z, Golik A, Weissgarten J: ACE inhibitors and survival of hemodialysis patients. Am J Kidney Dis 40 : 1023 –1029, 2002[CrossRef][Medline]
  29. Kestenbaum B, Gillen DL, Sherrard DJ, Seliger S, Ball A, Stehman-Breen C: Calcium channel blocker use and mortality among patients with end-stage renal disease. Kidney Int 61 : 2157 –2164, 2002[CrossRef][Medline]
  30. Foley RN, Herzog CA, Collins AJ: Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study. Kidney Int 62 : 1784 –1790, 2002[CrossRef][Medline]
  31. Agarwal R: Supervised atenolol therapy in the management of hemodialysis hypertension. Kidney Int 55 : 1528 –1535, 1999[CrossRef][Medline]
  32. Agarwal R, Lewis R, Davis JL, Becker B: Lisinopril therapy for hemodialysis hypertension: Hemodynamic and endocrine responses. Am J Kidney Dis 38 : 1245 –1250, 2001[Medline]




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