Pulmonary hypertension and right ventricular dysfunction in hemodialysis: an overlooked cardiorenal interface and a target for dialysis prescription

Pulmonary hypertension is an under-recognized cardiovascular complication of advanced chronic kidney disease, especially in maintenance hemodialysis. It links kidney failure, chronic volume stress, left-heart disease, pulmonary vascular remodeling, arteriovenous access flow, and right-ventricular dysfunction. This review frames pulmonary hypertension as central to the cardiorenal interface in hemodialysis and summarizes epidemiology, prognosis, mechanisms, diagnosis, and phenotyping. Echocardiography is the main screening tool, but pressure estimates should be interpreted according to dialysis timing and volume status. Right-heart catheterization remains essential to define phenotype and guide management. Treatment should target modifiable drivers: euvolemia without excessive ultrafiltration, optimized left-heart disease care, assessment of high-flow vascular access, and treatment of respiratory or hematologic contributors. Empirical pulmonary arterial hypertension-specific therapy should be avoided without hemodynamic confirmation. Pulmonary-artery denervation is promising in heart-failure pulmonary hypertension with mild to moderate CKD, but its role in hemodialysis remains unknown.