Walter H. Hörl

Abstract
Hypertension is a risk factor for cardiovascular morbidity and mortality. Hypertension affects the majority of haemo- dialysis (HD) patients. However, in the absence of prospect- ive data, accurate assessment of blood pressure (BP) and the level to which BP should be targeted remain still to be de- fined. A direct relationship between volume status and BP as well as between hypervolaemia and morbidity and mor- tality in HD patients indicates that normovolaemia is the key therapeutic target. Dry-weight reduction by additional ultra- filtration (even in the absence of clinical signs of volume overload) combined with daily dietary salt restriction or in- dividually lowered dialysate sodium is recommended. Strict volume control allows marked reduction of antihyperten- sive drug treatment or makes it even unnecessary. Long, slow, home HD or frequent, short HD sessions or nocturnal HD also result in reduction of BP and left ventricular hyper- trophy in end-stage renal disease patients. It will be interest- ing to see which recommendations will come from a conference sponsored by the Kidney Disease: Improving Global Outcomes on optimal BP treatment target in relation to end-organ damage and outcomes in HD patients, on anti- hypertensive drugs and on non-pharmacological therapies are to be considered in achieving BP targets in this popula- tion based on a paucity of prospective data.

Summary

During my second site visit I presented a patient with a history of HTN and ESRD on HD. The patient had elevated BP and evidence of fluid overload and was sent for inpatient hemodialysis. I wanted to learn more about management of HTN and the goal BP for patients with ESRD on HD. This review article aimed to define how to best assess BP and the target BP for patients with HTN and ESRD on HD. There presently is no consensus for the level to which BP should be lowered in these patients. NKF-KDOQI recommend peri-dialytic BP target of <140/90 pre-dialysis and <130/80 post-dialysis however these measurements are associated with intra-dialytic hypotension. Intra-dialytic hypotension is associated with increase in mortality due to decrease in myocardial perfusion. Often this hypotension is due to the use of anti-hypertensive medications interfering with compensatory mechanisms in the face of changes in intravascular volume. Observational studies show optimal risk with pre-dialysis systolic BP between 140-160 and diastolic 70-90 and post-dialysis systolic 135-154 and diastolic 70-90. A robust association was found between lower pre-dialysis systolic BP and higher risk of all-cause and cardiovascular mortality. The article also assessed which anti-hypertensive medications were most effective in this population. Significant decrease in death and hospitalization rates were seen in patients on carvedilol. Other medications assessed include amlodipine, ACEI, and ARB and found little or no reduction in morbidity and mortality. The relationship between volume status and BP and morbidity and mortality is known. Normovolemia is the key target for evaluating BP and the need for antihypertensive drugs. Reduction of weight post-dialysis is associated with decrease in systolic BP and mortality. Strict volume control can lead to reduced need for antihypertensive medications or even make their use unnecessary and potentially dangerous due to hypotension and inhibition of compensatory mechanisms and vasoconstriction. Authors conclude that while antihypertensive medications may reduce cardiovascular complications it is still premature to make general recommendations due to the heterogeneous population.

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