Case-based review
Management of Hypertension in the End-Stage
Renal Disease Patient
M. Salman Singapuri, MD, and Janice P. Lea, MD, MSc
Abstract
• Objective: To discuss mechanisms involved in blood
pressure dysregulation in patients on hemodialysis
and present strategies to improve blood pressure
control in end-stage renal disease (ESRD) patients.
• Methods: Review of the literature.
• Results: Blood pressure control is not adequate in
a vast majority of hemodialysis patients, which in
turn translates into an elevated rate of cardiovas-
cular disease. Although ambulatory blood pressure
monitoring provides a superior assessment of blood
pressure, its utilization is limited. Home blood pres-
sure measurements are a reliable and inexpensive
method to help diagnose occult hypertension in
chronic hemodialysis patients. Aiming for a blood
pressure of less than 140/90 mm Hg or the lowest
possible value as tolerated by the patient should
be the target. Achievement of dry weight is a key
factor in obtaining optimal blood pressure control.
Salt restriction to less than 2 g per day should be
reinforced. Adequate blood pressure control usually
will require pharmacologic therapy and it should be
tailored according to the physiology of the patient as
well as to the presence of other end-organ damage
and disease comorbidities.
• Conclusion: To reduce the disease burden in pa-
tients with ESRD, vigorous control of hypertension erine drip and transferred to a facility for further manage-
is recommended.
H
ypertension is a strong (particularly the systolic com-
ponent) and independent risk factor for cardiovascu-
lar disease in the general population [1]. It occurs in
an estimated 72 million people in the United States [2]. Hyper-
tension is the second leading cause of end-stage renal disease
(ESRD) in the United States and accounts for 30% of the ESRD
population [3]. Over the past 2 decades, the prevalence and
incidence of ESRD have been increasing [4]. Hypertension
is both a cause and consequence of kidney disease, as the
prevalence of hypertension in patients on dialysis is as high
as 90% [5–8]. It is associated with an annual mortality of 23%
[6], mainly from cardiovascular disease [9]. Interestingly, only
www.turner-white.com Vol. 17, No. 2
a minority of patients on hemodialysis have satisfactory blood
pressure control [10]; there is better control in the peritoneal
dialysis population. Reducing the morbidity and mortality
associated with hypertension is of paramount importance,
and understanding its etiology in chronic dialysis patients is
critical in order to optimize treatment [5]. A range of strategies
may be used and should be understood to improve control of
blood pressure. To reduce the disease burden in patients with
ESRD, vigorous control of hypertension is recommended [11].
In this article, we review different aspects of hypertension,
focusing mainly on the hemodialysis population.
CASE STUDY
Initial Presentation
A 51-year-old African American female presents to
the local emergency department with shortness of
breath and chest pain.
History
The patient has a history of diabetes mellitus, uncontrolled
hypertension, and ESRD secondary to hypertension on he-
modialysis for 1 year. Chest x-ray shows cardiomegaly and
pulmonary edema. Electrocardiogram is consistent with left
ventricular hypertrophy, and echocardiogram confirms the
same with an ejection fraction of 45%, notable for diastolic
dysfunction. She is initiated on a beta blocker and nitroglyc-
ment. She states that her blood pressure has been difficult
to control for the past 20 years and is noted to be high even
after hemodialysis. She denies use of tobacco, alcohol, or
drugs and is compliant with her medications. She does not
exercise but strictly adheres to a low-sodium diet.
Physical Examination
The patient is 67 inches tall and weighs 161 lb. She appears
healthy but in slight respiratory distress. Blood pressure
is 246/131 mm Hg, heart rate is 94 bpm, and body mass
From the Division of Nephrology and Hypertension, Emory University School of
Medicine, Atlanta, GA.
February 2010 JCOM 87
 hypertension management
Table 1. Mechanisms of Hypertension in End-Stage
Renal Disease
Sodium and volume overload
Inappropriate renin secretion
Sympathetic nervous system activity
Alterations in endothelin and nitric oxide
Erythropoietin therapy
Electrolyte disturbances
Hyperparathyroidism—increased intracellular calcium
index (BMI) is 27.4 kg/m2. Neck examination reveals jugular
venous distention to 10 cm. Heart auscultation is notable
for S3 and S4 and lung examination reveals crackles up to
mid-lung fields. Abdominal examination does not reveal
organomegaly or renal bruit. Pitting edema (2+) up to mid-
shin is appreciated in both lower extremities.
• What mechanisms are responsible for development of
hypertension in ESRD?
The pathophysiology is complex, and multiple mechanisms
are likely involved in blood pressure dysregulation in pa-
tients on hemodialysis [11]. Initial studies aimed at elucidat-
ing the pathophysiology of hypertension in this category of
patients concluded that 90% of cases resulted from sodium
and volume overload (volume-dependent), while the ma-
jority of the remaining had elevated renin activity (renin-
dependent), resulting in a rise in renin and blood pressure
during hemodialysis as fluid is removed [12].
There are a multitude of additional factors that dis-
tinctly affect hypertension. Erythropoietin acts via various
mechanisms, including increased blood viscosity, vascular
endothelial dysfunction, and direct vasoconstrictor effects
[5]. Other factors such as increased sympathetic outflow, as
measured by excessive catecholamine release [13] and vaso-
active substances (eg, endothelin, sodium pump inhibitors,
and nitric oxide synthetase inhibitors) contribute to the me-
chanics of hypertension. Of these, nitric oxide was the first
to be identified [14], which may cause vasodilatation and
inhibition of vascular smooth muscle cell proliferation [15].
It is inhibited by asymmetric dimethylarginine (ADMA),
which accumulates in hemodialysis patients [16]; their levels
are 6- to 10-fold higher as compared with healthy subjects.
ADMA may inhibit nitric oxide synthases, and hemodialy-
sis can reduce plasma concentration by 65% [17].
Other possible mechanisms include calcium-related
metabolic alterations that occur in ESRD. Patients with
ESRD develop secondary hyperparathyroidism, which in
88 JCOM February 2010 Vol. 17, No. 2 www.turner-white.com
turn causes entry of calcium into smooth muscles of blood
vessels leading to vasoconstriction and hypertension [18]. In
a study by Fliser et al [19], infusion of physiologic doses of
parathyroid hormone increases blood pressure and intracel-
lular calcium in healthy subjects. However, treatment with
alfacalcidiol, an active vitamin D analogue, significantly de-
creased parathyroid hormone, platelet intracellular calcium,
and mean blood pressure [20]. See Table 1 for mechanisms
of hypertension in ESRD.
In brief, the mechanisms of hypertension are difficult to
unravel in patients on hemodialysis given their intricacy. The
heterogeneity of the dialysis population results in probable
significant overlap of the above-mentioned causes. However,
a majority consensus agrees that the most predominant fac-
tor is related to expanded extracellular volume.
• What is the optimal blood pressure goal in patients on
dialysis?
Hemodialysis patients in general have an elevated systolic
blood pressure, but the diastolic blood pressure seems to
decrease, and the resultant effect is a high pulse pressure, re-
sulting in catastrophic effects on the cardiovascular system
[21]. No randomized prospective trials have evaluated target
blood pressure in dialysis patients. According to the Nation-
al Kidney Foundation K/DOQI guidelines, predialysis and
postdialysis blood pressures should be less than 140/90 and
less than 130/80 mm Hg, respectively [22]. However, these
guidelines are unfortunately not applicable to the hemodi-
alysis population. Ideal blood pressure in a hemodialysis
patient should be associated with hemodynamic stability
during dialysis, orthostatic tolerance after dialysis, the best
cardiovascular survival, and optimal health-related quality
of life [23]. There is confounding data regarding goals.
According to an observational study by Port et al [24] on
ap­proximately 4500 individuals on hemodialysis, a significant­
ly increased adjusted mortality risk was noticed among pa­
tients with a low predialysis systolic pressure (< 110 mm Hg)
but no association with an elevated mortality risk could be
observed for predialysis systolic hypertension except for an el-
evated risk of cerebrovascular death risk. Postdialysis systolic
pressures (> 180 mm Hg) and diastolic pressures (> 110 mm
Hg) were associated with an elevated mortality risk as well.
Also, in a retrospective analysis of 13,792 incident hemodialy-
sis patients by Tentori et al [25], patients were evaluated for
correlation between survival and achieving K/DOQI clinical
practice guidelines for multiple parameters. Achieving the
goal predialysis blood pressure of less than 140/90 mm Hg
was associated with an increased mortality.
Opinion-based recommendations are offered, but goals

should be individualized based on a complete assessment
of prevailing comorbidities and should target normalization
of the pulse pressure [26]. In general, an ideal goal for post-
dialysis systolic blood pressure seems to be a value higher
than 110 mm Hg and lower than 150 mm Hg. However,
hemodialysis patients are generally older and often have
cardiac complications, so a reasonable predialysis target
systolic blood pressure could be 150 mm Hg [21]. A random-
ized controlled trial is needed to identify the optimal blood
pressure for hemodialysis patients.
• Which measurement of blood pressure is better: predi-
alysis, postdialysis, or home?
There are several issues relating to blood pressure mea-
surement that may be unique to hemodialysis patients. For
example, the presence of a functioning dialysis access in
one extremity may limit the measurement of blood pres-
sure to the other arm. The standard recommendation that
blood pressure be measured in both arms and the higher
value used as the representative one cannot be applied in
this population [27]. In addition, there is loss of the normal
nocturnal decline in blood pressure [28], which is associated
with adverse cardiovascular outcomes.
There are conflicting data as to whether blood pressure
measurements before or after dialysis sessions are reliable
predictors of interdialytic blood pressure. According to
Mendes et al [29], postdialysis values are minimally bet-
ter predictors than predialysis blood pressures, and the
average of pre- and posthemodialysis values is marginally
better than both. Similarly in a study by Mitra et al [30], the
best representation of interdialytic blood pressure was the
20-minute postdialysis reading. His study also concluded
that walk-in predialysis pressures overestimate mean inter-
dialytic pressures due to a high incidence of white-coat ef-
fect. In contrast to this, Zoccali’s [31] concept is that predialy-
sis blood pressure was a better predictor of left ventricular
mass index than postdialysis blood pressure.
Predialysis systolic blood pressure may overestimate the
mean interdialytic systolic blood pressure by 10 mm Hg,
while the postdialysis systolic blood pressure may under-
estimate the mean systolic blood pressure by 7 mm Hg [32].
Some studies, however, have suggested that the postdialysis
blood pressure may be more reflective of interdialytic blood
pressure [32,33]. Ambulatory blood pressure monitoring
(ABPM) is another modality of assessing intradialytic blood
pressure assessment and is the gold standard for the diag-
nosis of white-coat hypertension [28]. It has been in use for
more than 4 decades. According to Peixoto [34], ABPM has
www.turner-white.com Vol. 17, No. 2
Case-based review
generally been considered the most accurate method for
studying blood pressure in hemodialysis patients over time.
ABPM involves wearing a small device usually hooked to
the belt that is connected via a hose to a blood pressure
cuff around the arm. While the patient goes about his usual
activity, the device automatically inflates at 20- to 30-minute
intervals and records the blood pressure and heart rate.
In a study by Amar et al [35] involving 57 hypertensive
hemodialysis patients, it was noted that measuring 24-hour
pulse pressure via ABPM was an independent predictor of
cardiovascular mortality. Although ABPM provides useful
data, it is difficult to use this technology for the routine
management of hypertension in hemodialysis patients. In
summary, interdialytic ABPM closely correlates with left
ventricular hypertrophy [36] and all-cause mortality [37]
compared with blood pressure recordings in the dialysis
units and, in contrast with home blood pressure recordings,
offers greater insight into circadian rhythms [28].
In a recent review by Agarwal [37], it was noted that
home blood pressure readings are also superior to diagnose
hypertension. Agarwal et al [38] noted that a home systolic
blood pressure of ≥ 150 mm Hg averaged over 1 week had
the best combination of sensitivity (80%) and specificity
(84.1%) in diagnosing systolic hypertension. Monitoring of
blood pressure at home is a cost-effective means that could
help diagnose occult hypertension in chronic hemodialysis
patients [39]. A composite of blood pressure measurements
over a period of 1 to 2 weeks rather than isolated readings
should be used for guidance [40].
• What complications related to hypertension are seen in
ESRD?
In this case, the patient developed hypertensive emergency
resulting in congestive heart failure (CHF) despite being on
dialysis and multiple medications, indicative of inadequate
fluid removal. Hypertensive emergencies are defined as
acute, life-threatening, and usually extreme increases in
blood pressure and are associated with acute end-organ
damage [41]. CHF is highly prevalent and is a leading cause
of death in such patients. Patients on hemodialysis are also
at particular risk of hemorrhagic strokes because of chronic
exposure to heparin, as well as to acute coronary events.
Left ventricular hypertrophy (LVH) is common in hyper-
tensive patients and is endemic in the ESRD population
[42]. Hypertension may contribute to the development of
atherosclerotic coronary artery disease, particularly in the
presence of the many lipid abnormalities observed in ESRD
[43]. Hypertension, anemia, and comorbid conditions such
February 2010 JCOM 89
 hypertension management
as coronary artery disease are particularly important risk
factors for CHF in ESRD [44].
• How is hypertension managed in patients who have
ESRD?
Management of patients on hemodialysis is challenging
[45]. It may be dichotomized into 2 broad categories: non-
pharmacologic and pharmacologic.
Nonpharmacologic Management
Reduction of salt intake is the first keystone of therapy
to achieve adequate blood pressure control. According to
Mailloux [46], salt restriction is often overlooked as a means
of controlling hypertension in this population of patients.
Historically, in 1944 Kempner [47] published the first re-
ported benefit of a reduced dietary salt intake in controlling
hypertension in patients with chronic renal failure. The first
mention of the ability to control hypertension in hemodialysis
patients without the use of medications was in 1961 [48]. The
first 4 patients treated by long-term dialysis in Seattle were
hypertensive, and their hypertension was well controlled by
a low-sodium diet and ultrafiltration alone. Drug therapy had
been stopped in 3 patients as it was producing too many side
effects and was relatively ineffective [48].
It has been anticipated that salt restriction to 1000 mg/day
or less helps decrease thirst and control interdialytic fluid
gain [49], although a 2-g sodium restriction is usually pre-
scribed for most hemodialysis patients. A 2-g sodium restric-
tion equates to an interdialytic weight gain of 1.25 kg over
2 days; however, this is rarely achieved. Sodium balance may
also be addressed by reducing dialysate sodium concentra-
tion. In a study by Flanigan et al [50], there was a reduction in
both the number of antihypertensive medications prescribed
and blood pressure by gradually lowering the sodium con-
centration in the last 30 minutes of hemodialysis.
Improvement of blood pressure control is necessary
in the hemodialysis population, first by slow and smooth
removal of extracellular volume (dry weight) and thereaf-
ter by the use of appropriate antihypertensive medication
[21]. The term “dry weight” was first coined by Thomson
in the 1970s [51] and has been defined as not merely the
absence of edema but the minimal body sodium content
and volume of body water that can be tolerated without
inducing hypotension [52]. It is assessed by history, pre- and
posthemodialysis blood pressures (including orthostatics),
examination of neck veins, and presence of edema [53].
Gradual fluid removal with longer dialysis permits a greater
degree of total fluid loss and attaining the dry weight. Ac-
cording to a recent randomized controlled trial conducted
90 JCOM February 2010 Vol. 17, No. 2 www.turner-white.com
by Agarwal [54], it was found that reduction of dry weight
is a simple, efficacious, and well-tolerated maneuver to help
improve hypertension in hemodialysis patients. However,
achieving a lower dry weight and decreasing blood pres-
sure by such an approach is not immediate, and it could
take weeks or months before a stable reduction in blood
pressure is noticed; Charra et al [55] has labeled this “the
lag phenomenon.” This was shown in a group of 61 patients,
wherein 6 months were necessary for predialysis mean
blood pressure to reach a plateau of normal values after the
dry weight method and tapering of antihypertensive drugs
were applied [56]. Dry weight is a very subjective measure
determined by the nephrologist after observing several di-
alysis sessions for the absence of edema, low blood pressure,
and/or the occurrence of cramps. Dry weight also has to
be continually monitored, as the patients’ flesh weight may
change according to dietary intake, and thus the dry weight
or fluid weight (ie, the amount of fluid gained in between
hemodialysis treatments) will also need to be changed, or
patients can become either volume overloaded or too dry,
resulting in severe hypotension, syncope, and cardiovascu-
lar events.
Supporting the concept that achievement of true dry
weight improves blood pressure control is the fact that
patients who perform daily dialysis, whether it is peritoneal
dialysis or daily hemodialysis, have much better blood pres-
sure control and require less antihypertensive medication
[57]. Furthermore, a randomized controlled trial by Culleton
et al [58] revealed that compared with conventional hemo-
dialysis (3 times weekly), frequent nocturnal hemodialysis
improved left ventricular mass, reduced the need for blood
pressure medications, improved some measures of mineral
metabolism, and improved selected measures of quality of
life. In a study done by Pierratos et al [59], nocturnal hemo-
dialysis proved to be the most efficient form of dialysis at a
low cost with improved blood pressure control.
Other nonpharmacologic strategies, including exercise,
weight loss in obese individuals, discontinuing tobacco,
and limiting alcohol intake, may also contribute to achieve
hypertension management goals, as they are effective in
the general population [60]. Aerobic exercise has been sug-
gested in many patient populations, including those with
chronic renal failure, as a measure to control blood pressure.
According to a study by Miller et al [61] conducted on 107
patients, it was observed that the average relative benefit of
exercise was a 36% reduction in antihypertensive medica-
tions (P = 0.018) with an average annual cost savings of $885
per patient-year (P = 0.005) in the exercise group.
Pharmacologic Management
According to Agarwal and Sinha [62], randomized trials
suggest benefits of antihypertensive therapy among hemodi-
 Case-based review

alysis patients. Of note, randomized trials on angiotension- Table 2. Antihypertensive Medications

converting enzyme (ACE) inhibitors, beta blockers, calcium
Approximate Cleared by
channel blockers (CCBs), and angiotensin-receptor blockers
Class Half-Life, hr Hemodialysis?
(ARBs) within the past few years have shown attenuation of
cardiovascular disease. Essentially all classes of antihyperten- Adrenergic receptor blockers
sive medications are useful in anuric hemodialysis patients α-Antagonist
with the exception of diuretics [63]. Dosing, frequency, and Doxazosin 22 No
type of medication is influenced by their pharmacokinetic pro- Prazosin 5 No
files [63]. Antihypertensive agents need to be tailored in accor- Terazosin 12 No
dance with underlying disease profile in hemodialysis patients, β-Antagonist
and no specific class of antihypertensive drug has proven to Abebutalol 3 Yes
be more beneficial than others [9]. Randomized controlled Atenolol 6 Yes
clinical trials are needed to determine the most advantageous Bisoprolol 10 Yes
antihypertensive agent(s) to use in ESRD patients on chronic Carvedilol 10 No
hemodialysis. Among all classes, CCBs are the most commonly Labetalol 4 ?
prescribed antihypertensive agents [6] and offer the advantage Propranolol 4 No
of not being cleared during hemodialysis [64] (Table 2). Propranolol LA 10 No
The role of diuretics in the management of hemodialysis Metoprolol 5 Yes
patients has not been clearly defined. An observational Vasodilators
study by Bragg-Gresham et al [65] suggested there may be a Hydralazine 5 No
survival advantage to diuretic use in hemodialysis patients Minoxidil 4 Yes
with little to no residual renal function. Patients on continu-
Angiotensin-receptor blockers
ous ambulatory peritoneal dialysis (CAPD) are dependent
Irbesartan 12 No
on residual renal function for solute and water clearances,
Losartan 5 No
and this declines with time on dialysis. In a prospective,
Valsartan 6 No
randomized, open-label study, Medcalf et al [66] showed
Candesartan 10 No
that furosemide given at 250 mg per day produced a clini-
ACE inhibitors
cally significant preservation in urine volume over 1 year of
Benazepril 10 No
CAPD. This was associated with a possible improvement in
Captopril 2 Yes
fluid balance and no increase in side effects but did not have
effect on preserving residual renal function. Enalapril 11 Yes
However, because the renin-angiotensin system is active Fosinopril 12 No
in many ESRD patients and because of the high cardio- Lisinopril 12 Yes
vascular disease burden, ACE inhibitors and ARBs are an Calcium channel blockers
attractive class of medications for the ESRD population. Amlodipine 40 No
According to Takahashi et al [67], the ARB candesartan Diltiazem 5 No
significantly reduced cardiovascular events and mortality in Nifedipine 2 No
patients on chronic maintenance hemodialysis and therefore Nisoldipine 10 No
improved the prognosis of such patients. Similarly, a study Verapamil 8 No
by Suzuki et al [68] concluded that ARBs may be effective in
ACE = angiotensin-converting enzyme; LA = long-acting.
reducing nonfatal CVD events in patients undergoing long-
term hemodialysis. In an observational study Efrati et al [69]
showed that ACE inhibitors, independently of their antihy- erythropoietin resistance [71]. N-acetyl-seryl-aspartyl-lysyl-
pertensive effect, may dramatically reduce mortality among proline (AcSDKP) is a physiological inhibitor of hematopoi-
chronic hemodialysis patients 65 years or younger. Of par- esis [72] and is degraded by ACE. AcSDKP accumulates in
ticular interest, a randomized controlled study by Li et al patients with ESRD and may explain erythropoietin hypo-
[70] showed that the ACE inhibitor ramipril may slow the responsiveness, particularly in patients treated with ACE
rate of decline in residual renal function by 0.93 mL/min per inhibitors [23]. In addition, a high incidence of anaphylactoid
1.73 m2 per year in CAPD patients and reduce the progres- reaction with the AN69 dialyzer has been reported in ESRD
sion to anuria [70]. patients on ACE inhibitors.
ACE inhibitors notoriously cause hyperkalemia, but in- Another option available is the weekly application of a
terestingly in ESRD patients they may cause development of transdermal clonidine patch [73]. Minoxidil, a potent vaso-

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 hypertension management
dilator, may also be used, but caution should be observed as
they are normally excreted through the kidneys [74] and it
should be used with a beta blocker to maintain efficacy. Its
main side effects include hirsutism, pericardial effusion, and
edema, which can be problematic in dialysis patients. Most
ACE inhibitors as well as beta blockers are removed with di-
alysis, while CCBs and ARBs are not and are of particular sig-
nificance especially for patients exhibiting a renin-dependent
form of hypertension, ie, blood pressure rises throughout the
hemodialysis procedure with higher posthemodialysis renin
levels than prehemodialysis (Table 2).
• What is the impact of residual renal function in dialysis
patients?
Residual renal function is an important factor influencing
mortality in dialysis patients [75] and has achieved immense
recognition in the past 2 decades. It is generally present
in patients being initiated on hemodialysis or peritoneal
dialysis but tends to decrease over time. It is of essential
importance to dialysis adequacy, morbidity, and mortality,
particularly in long-term CAPD patients [76]. Residual renal
function contributes significantly to the overall health and
well-being of dialysis patients. It provides small solute clear-
ance, plays an important role in maintaining fluid balance,
phosphorus control, removal of middle molecular uremic
toxins, and shows strong inverse relationships with valvular
calcification and cardiac hypertrophy in dialysis patients.
Balancing sodium intake and removal is easier with residual
renal function since sodium removal can be increased by
diuretics. Furthermore, patients with residual renal function
have fewer problems with potassium.
However, the decline of residual renal function contrib-
utes significantly to anemia, inflammation, and malnutri-
tion. More importantly, its loss is a powerful predictor of
mortality, especially in patients on peritoneal dialysis [77].
Whereas the role of residual renal function for survival is
well recognized in the peritoneal dialysis population, it has
not received much attention in the hemodialysis population.
In a recent study by Vilar et al [78], there were strong data
showing that residual renal function contributes signifi-
cantly to improved outcomes in hemodialysis patients and
that efforts to preserve it are warranted. However, compara-
tive outcome studies should be controlled for the presence of
residual renal function.
Patient Follow-up
The patient’s dry weight at the outpatient hemodi-
alysis center was 77 kg. Review of her outpatient
hemodialysis flow sheets revealed that her predialysis blood
92 JCOM February 2010 Vol. 17, No. 2 www.turner-white.com
pressure was ranging from 160 to 170/80 to 85 mm Hg and
postdialysis blood pressure from 150 to 160/75 to 85 mm Hg.
During the hospitalization, her dry weight was lowered to
73 kg and dosages of her blood pressure medications ad-
justed. An ARB was added as part of her regimen to provide
cardiac protection, LVH regression, and better control of
hypertension even during the hemodialysis session. She then
achieved prehemodialysis blood pressures of 145 to 150/70 to
75 mm Hg and posthemodialysis blood pressures of 120 to
131/62 to 71 mm Hg. Interdialytic blood pressures were rang-
ing between 125 to 141/63 to 68 mm Hg. As an outpatient she
was instructed not to take any of her blood pressure medi-
cations the morning of her scheduled dialysis, a common
practice to avoid intradialytic hypotension; consequently, her
prehemodialysis systolic blood pressures were elevated and
averaging greater than 160 mm Hg. While in the hospital, she
was allowed to take one of her blood pressure medications,
an ARB, before hemodialysis for better control of her blood
pressure throughout the dialytic process.
Summary
Blood pressure control is not adequate in a vast majority
of hemodialysis patients, which in turn translates into an
elevated rate of CVD. Compared with the general popula-
tion, the incidence of CVD is approximately 10- to 20-fold
in ESRD patients and it is a major cause of death [79]. Blood
pressure measurements should be performed customarily
in patients with ESRD. Although ABPM provides a superior
assessment of blood pressure monitoring, its low practicality
limits its utilization. Home blood pressure measurements
are a reliable and inexpensive method of tracking blood
pressure recordings and provide a tool for the diagnosis
of obscured hypertension. Of note, it best correlates with
ABPM and LVH. Aiming for a blood pressure of less than
140/90 mm Hg or the lowest possible value as tolerated by
the patient should be the target. Achievement of dry weight
is a key factor in obtaining optimal blood pressure control.
Salt restriction to less than 2 g per day should be reinforced
repeatedly to ESRD patients. Adequate blood pressure con-
trol usually will require pharmacologic therapy as well and
should be tailored according to the physiology of the patient,
ie, renin-dependent, as well as to the presence of other end-
organ damage and disease comorbidities. There are no stud-
ies specifically addressing which class of antihypertensive
drugs provide better organ protection in dialysis patients;
however, ACE inhibitors and ARBs are recommended as
the principal choices given their protective effects in patients
with or at risk for cardiovascular disease [80].
Other practical issues for treating hypertension in hemo-
dialysis patients include generally holding blood pressure
medications the morning of the hemodialysis session to
avoid intradialytic hypotension to allow achievement of true

dry weight. However, some patients, especially those with
renin-dependent hypertension, will benefit from dosing
an ARB or a nonrenally excreted ACE inhibitor either the
morning of or the night before hemodialysis. Renin levels
can be measured pre- and posthemodialysis to determine
if there is benefit of using a RAS blocker. Other agents that
are not removed with hemodialysis are ideal for those with
continued hypertension throughout the hemodialysis ses-
sion. Diuretic use in those with residual renal function may
be helpful in managing intravascular volume, especially
in the peritoneal dialysis population. Despite the lack of
randomized controlled trials in dialysis patients, adequate
blood pressure control, as is recommended in the nondialy-
sis population, should be emphasized.
Corresponding author: Janice P. Lea MD, MSc, Emory University School
of Medicine, Div. of Nephrology and Hypertension, 550 Peachtree St. 8th
Fl., Atlanta, GA 30308, jlea@emory.edu
Financial disclosures: None.
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