The Challenges of Blood Pressure Control in Hemodialysis Patients

Hypertension is extremely common in hemodialysis patients. The etiology is multifactorial, with a large contribution from extracellular volume overload and additional contributions from increased activity of the renin-angiotensin-aldosterone system, sympathetic nervous system, as well as endothelial cell dysfunction. The diagnosis of hypertension and the prognosis of the recorded blood pressure (BP) are best established using interdialytic measurements or incorporation of multiple intradialytic or per-dialytic measurements. Major obstacles in the management of hypertension include the frequent changes that occur in BP during and between dialysis. There are no clinical trials to establish the appropriate target BP for hemodialysis patients, but clinicians should aim to optimize extracellular volume while simultaneously avoiding excessive ultrafiltration and intradialytic hypotension. Many patients also require BP medications, and there is no consensus on the most appropriate first-line agent with regard to improving mortality. Renin-angiotensin-aldosterone system antagonists, adrenergic receptor blockers, and calcium channel blockers are some of the most commonly prescribed agents. Despite the widespread prevalence of hypertension among dialysis patients, the optimal management approach requires consideration of specific factors relevant to each individual patient.