Hypertension Goals in Advanced-Stage Kidney Disease

Hypertension confers higher cardiovascular (CV) risks in hemodialysis (HD) patients. There are no data to guide the level to which BP should be reduced or when and where to measure BP in such patients. Unlike BP guidelines to reduce CV risk in the general population, no uniform guidelines address the HD patient. This article focuses on when and how to measure BP and efforts to quantify this measure in the HD-dependent patient. A U-shaped curve exists between BP level and mortality in HD patients, with higher mortality noted at lower levels of BP <120 mmHg and levels >180 mmHg measured before HD. Previous studies examined risk reduction through evaluating BP readings from dialysis units. Peridialysis values were biased and, thus, less representative of risk. Newer studies using home BP and ambulatory BP during 24 h have provided a narrower range of BP values that may reduce CV risk but must be tested in a clinical trial. Ambulatory BP monitoring is a growing tool for hypertension evaluation along with changes in vascular compliance; however, these methods are mainly used in research settings. Home BP values on interdialytic days are practical and also demonstrate good correlations with ambulatory readings. Aggressive volume control seems key to maintaining good BP control. Once a valid time and measure for BP is agreed on, a clinical outcome trial is needed to test its utility.