How to Manage Hypertension in End-stage Renal Disease

Since dialysis patients are cared for mainly by nephrologists, does that mean that our non-nephrology colleauges have no place in the blood pressure management of these patients? The following questions and answers point to important roles for physicians outside nephrology and suggest tools to help diagnose and treat hypertension in end-stage renal disease.

1. Which of the following statements are true?

A. The most important blood pressure readings in dialysis patients are either outside the dialysis unit or by ambulatory blood pressure monitoring (ABPM).

B. Forty-four hour ABPM (the consecutive time in the middle of the week in between dialysis treatments) is the gold standard for blood pressure readings in dialysis patients.

Answer, discussion, and next question>>

Answer: Both statements are true.

Elevated blood pressures in dialysis patients outside of the dialysis unit at home or by ABPM are directly associated with decreased survival.¹ Elevated ABPM values in dialysis patients are better correlated with left ventricular hypertrophy and cardiovascular mortality than predialytic or postdialytic blood pressures.¹

2.  Regarding choice of antihypertensive agents in dialysis patients which answer/s is/are correct?

A. Diuretics are important for blood pressure control in dialysis patients.

B. Studies have demonstrated that beta blockers in dialysis patients decrease sudden death.

C. Although atenolol has lost favor as an antihypertensive for patients not on dialysis, in individuals on dialysis, it prevented serious cardiovascular events.

D. Angiotensin receptor blockers and angiotensin converting enzyme inhibitors are interchangeable for blood pressure control in dialysis patients.

Answer, discussion, and next question>>

Answer: B and C are correct¹

Volume excess as a cause of increased blood pressure in dialysis patients is best treated by lowering dry weight, not with diuretics. Angiotensin converting enzyme inhibitors are dialyzable, but receptor blockers are not, making them better antihypertensive agents in dialysis patients. Atenolol has important protective effects in the dialysis population when used to treat hypertension.

3. True or False: Mineralocorticoid receptor antagonists (MRA) like spironolactone should be avoided in dialysis patients.

A. True

B. False

Answer and discussion>>

Answer: B. False

Recent trials have demonstrated that MRAs decrease mortality and cardiovascular hospitalizations in the dialysis population.¹

There is a role for all healthcare professionals in diagnosing and treating hypertension in dialysis patients. Since blood pressure during dialysis may drop because of medications used to treat the disease and dry weight adjustments on dialysis benefit blood pressure, teamwork inside and outside the dialysis unit is critical. Blood pressure readings during non-nephrology visits are an important part of ongoing care for dialysis patients.

Source: Sarafidis PA, Persu A, Agarwal R, et al. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine working group. J Hypertens. 2017;35:657-676.