Epidemiology, diagnosis and management of hypertension among patients on chronic dialysis

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Abstract

The diagnosis and management of hypertension among patients on chronic dialysis is challenging. Routine peridialytic blood pressure recordings are unable to accurately diagnose hypertension and stratify cardiovascular risk. By contrast, blood pressure recordings taken outside the dialysis setting exhibit clear prognostic associations with survival and might facilitate the diagnosis and long-term management of hypertension. Once accurately diagnosed, management of hypertension in individuals on chronic dialysis should initially involve non-pharmacological strategies to control volume overload. Accordingly, first-line strategies should focus on achieving dry weight, individualizing dialysate sodium concentrations and ensuring dialysis sessions are at least 4 h in duration. If blood pressure remains unresponsive to volume management strategies, pharmacological treatment is required. The choice of appropriate antihypertensive regimen should be individualized taking into account the efficacy, safety, and pharmacokinetic properties of the antihypertensive medications as well as any comorbid conditions and the overall risk profile of the patient. In contrast to their effects in the general hypertensive population, emerging evidence suggests that β-blockers might offer the greatest cardioprotection in hypertensive patients on dialysis. In this Review, we discuss estimates of the epidemiology of hypertension in the dialysis population as well as the challenges in diagnosing and managing hypertension among these patients.

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Stephen S Lim, Theo Vos, Abraham D. Flaxman … (2012)

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Long interdialytic interval and mortality among patients receiving hemodialysis.

Robert N Foley, David T Gilbertson, Thomas Pinkney Murray … (2011)

Patients with end-stage renal disease requiring dialysis have limited tolerance of metabolic and volume-related deviations from normal ranges; in addition, the prevalence of cardiovascular disease is high among such patients. Given these problems, we hypothesized that a long interdialytic interval is associated with adverse events in patients receiving hemodialysis. We studied 32,065 participants in the End-Stage Renal Disease Clinical Performance Measures Project, a nationally representative sample of U.S. patients receiving hemodialysis three times weekly, at the end of calendar years 2004 through 2007. We compared rates of death and cardiovascular-related hospital admissions on the day after the long (2-day) interdialytic interval with rates on other days. The mean age of the cohort was 62.2 years; 24.2% of the patients had been receiving dialysis treatment for 1 year or less. Over a mean follow-up interval of 2.2 years, the following event rates were higher on the day after the long interval than on other days: all-cause mortality (22.1 vs. 18.0 deaths per 100 person-years, P<0.001), mortality from cardiac causes (10.2 vs. 7.5, P<0.001), infection-related mortality (2.5 vs. 2.1, P = 0.007), mortality from cardiac arrest (1.3 vs. 1.0, P = 0.004), mortality from myocardial infarction (6.3 vs. 4.4, P<0.001), and admissions for myocardial infarction (6.3 vs. 3.9, P<0.001), congestive heart failure (29.9 vs. 16.9, P<0.001), stroke (4.7 vs. 3.1, P<0.001), dysrhythmia (20.9 vs. 11.0, P<0.001), and any cardiovascular event (44.2 vs. 19.7, P<0.001). The long (2-day) interdialytic interval is a time of heightened risk among patients receiving hemodialysis. (Funded by the National Institutes of Health.).

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Effect of fluid management guided by bioimpedance spectroscopy on cardiovascular parameters in hemodialysis patients: a randomized controlled trial.

Soner Duman, Huseyin Toz, Ercan Ok … (2013)

Fluid overload is the main determinant of hypertension and left ventricular hypertrophy in hemodialysis patients. However, assessment of fluid overload can be difficult in clinical practice. We investigated whether objective measurement of fluid overload with bioimpedance spectroscopy is helpful in optimizing fluid status. Prospective, randomized, and controlled study. 156 hemodialysis patients from 2 centers were randomly assigned to 2 groups. Dry weight was assessed by routine clinical practice and fluid overload was assessed by bioimpedance spectroscopy in both groups. In the intervention group (n = 78), fluid overload information was provided to treating physicians and used to adjust fluid removal during dialysis. In the control group (n = 78), fluid overload information was not provided to treating physicians and fluid removal during dialysis was adjusted according to usual clinical practice. The primary outcome was regression of left ventricular mass index during a 1-year follow-up. Improvement in blood pressure and left atrial volume were the main secondary outcomes. Changes in arterial stiffness parameters were additional outcomes. Fluid overload was assessed twice monthly in the intervention group and every 3 months in the control group before the mid- or end-week hemodialysis session. Echocardiography, 48-hour ambulatory blood pressure measurement, and pulse wave analysis were performed at baseline and 12 months. Baseline fluid overload parameters in the intervention and control groups were 1.45 ± 1.11 (SD) and 1.44 ± 1.12 L, respectively (P = 0.7). Time-averaged fluid overload values significantly decreased in the intervention group (mean difference, -0.5 ± 0.8 L), but not in the control group (mean difference, 0.1 ± 1.2 L), and the mean difference between groups was -0.5 L (95% CI, -0.8 to -0.2; P = 0.001). Left ventricular mass index regressed from 131 ± 36 to 116 ± 29 g/m(2) (P < 0.001) in the intervention group, but not in the control group (121 ± 35 to 120 ± 30 g/m(2); P = 0.9); mean difference between groups was -10.2 g/m(2) (95% CI, -19.2 to -1.17 g/m(2); P = 0.04). In addition, values for left atrial volume index, blood pressure, and arterial stiffness parameters decreased in the intervention group, but not in the control group. Ambulatory blood pressure data were not available for all patients. Assessment of fluid overload with bioimpedance spectroscopy provides better management of fluid status, leading to regression of left ventricular mass index, decrease in blood pressure, and improvement in arterial stiffness. Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.